11
Property of the
Lancaster City and County
Medical Society
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I
THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
EDITED BY
ISAAC HAYS, A.M., M.D.,
AND
I. MINIS HAYS, A.M., M.D.
- N E W SEEIES.
VOL. LXXV.
PHILADELPHIA:
H E 1ST K Y C. LEA.
1878.
69501
Entered according to the Act of Congress, in the year 1878, by
HENRY C. LEA,
in the Office of the Librarian of Congress. All rights reserved.
PHILADELPHIA :
COLLINS, PRINTER,
705 Jayne Street.
TO READERS AND CORRESPONDENTS.
All communications intended for insertion in the Original Department of this
Journal are only received for consideration with the distinct understanding that
they are sent for publication to this Journal alone, and that abstracts of them
shall only appear elsewhere subsequently, and with due credit. Gentlemen
favouring us with their communications are considered to be bound in honour to
a strict observance of this understanding.
Contributors who wish their articles to appear in the next number are requested
to forward them before the 1st of February.
Compensation is allowed for original articles and reviews, except when illus-
trations or extra copies are desired. A limited number of extra copies (not
exceeding fifty) will be furnished to authors, jyrovided the request for them be
made at the time the communication is sent to the Editors.
The following works have been received : —
Klinisk Veiledering til Diagnose, Behandling og Forebyggelse af Veneriske Syg-
domme. Af Dr. S. Engelsted, Overlsege i Kommune Hospitalet og Klinisk Lserer
ved Universitetet. Kjobenhavn : C. A. Reitzels, 1877.
Traitement Rationnel des Plaies ; Methode d'Aeration. Rapport de la Commission
Speciale du Traitement des Plaies a la Societe de Chirurgie de Moscou, 10 Janvier,
1877. Moscou, 1877.
Ueber die Behandlung der Ganglien Mittelst Discission und Nachfolgender Com-
pression. Von Dr. Carl Fieber. Docent der Chirurgie au der Wiener ttniversitat.
Uber die Harder'sche Druse der Saiigethiere. Von Dr. Edmund C. Wendt, aus
New York. Strassburg, 1877.
Die Formen des Harnrohrentrippers und die Endoskopischen Befunde derselben.
Von Dr. Jos. Grunfeld in Wien.
Considerazioni Critiche intorno all'Avvelenamento Col Rame ed I Suoi Sali.
Seritte in Serrigio del Foro dal Dottor A. Feroci, Medico Pisano. Pisa, 1877.
Surgery — Past, Present, and Future, and Excessive Mortality after Surgical Opera-
tions. By T. Spencer Wells, F.R.C.S., Surgeon to the Queen's Household, etc.
London : J. & A. Churchill, 1877.
On Hare-lip and Cleft Palate. By Francis Mason, F.R.C.S., Surgeon and Lecturer
on Anatomy at St. Thomas's Hospital, etc. London : J. & A. Churchill, 1877.
The Spas of Aix-les-Bains and Marlioz, Savoy : their Physiological Action, Modes
of Application, Clinical Effects, and Analysis ; together with Practical Instructions.
By Francis Bertier, M.D., Paris. London : J. & A. Churchill, 1877.
Fistula in Ano. A double case ; one treated by the knife — the other by the elastic
ligature. By C. F. Maunder, Surgeon to the London Hospital. London : J. & A.
Churchill, 1877.
The Moiphology of the Skull. By W. K. Parker, F.R.S., Hunterian Prof. Royal
College of Surgeons, and G. T. Bettany, M.A., B.A. London : MacMillan & Co.,
1877.
Lectures on Clinical Medicine ; delivered in the Royal and Western Infirmaries of
Glasgow. By Dr. M'Call Anderson, Professor of Clin. Med. in Univ. of Glasgow.
London : MacMillan & Co., 1877.
The Treatment of Spina Bifida by a New Method. By James Morton, M.D., Prof,
of Mat. Med. Anderson's Univ. Glasgow : James Maclehose, 1877.
Notes on the Crania of the Botans of Formosa. By Stuart Eldridge, M.D. Yo-
kohama.
The Ear : its Anatomy, Physiology, and Diseases. A Practical Treatise for the Use
of Medical Students and Practitioners. By Charles H. Burnett, A.M., M.D., Aural
Surgeon to the Presbyterian Hospital. Philadelphia : Henry C. Lea, 1877.
A Guide to Therapeutics and Materia Medica. By Robert Farquharson, M.D.
Edin. Enlarged and adapted to the U. S. Pharmacopoeia by Frank Woodbury, M.D.,
Member of Acad, of Nat. Sci. Phila. Philadelphia : Henry C. Lea, 1877.
Forensic Medicine and Toxicology. By W. Bathurst Woodman, M.D., F.R.C.P.,
and Charles Meymott Tidy, MiD., F.C.S. Philadelphia: Lindsay & Blakistou,
Lectures on Practical Surgery. By H. H. Toland, M.D., Professor of Surgery in
University of California. Philadelphia : Lindsay & Blakiston, 1877.
8
TO READERS AND CO R R E S P 0 N D E X T S .
Materia Medica, for the Use of Students. By Johx B. Biddle, M.D., Prof, of Mat.
Med. and Gen. Therapeutics in Jefferson Med. College. Eighth edition. Revised and
enlarged. Philadelphia : Lindsay & Blakiston, 1877.
The Action of Medicines. By Isaac Ott, A.M., M.D. : formerly Demonstrator of
Exper. Phys. Univ. of Penna. Philadelphia : Lindsay & Blakiston, 1877.
Wood's Physicians' Vade-Mecum and Visiting List. Arranged and prepared by H.
C. Wood, M.D., Professor of Materia Medica and Therapeutics in Univ. of Penna.
Philadelphia : J. B. Lippincott & Co., 1877.
Cyclopaedia of the Practice of Medicine. Edited by Dr. H. vox Ziemssen, Vol.
XVI. Diseases of the Locomotive Apparatus, and General Anomalies of Nutrition.
Albert H. Buck, M.D., Editor of Am. ed. New York : William Wood & Co.. 1877.
Lectures on Fevers. By Alfred L. Loomis, A.M., M.D., Prof, of Path, and Prac.
Med. in University of City of New York. New York : William Wood & Co.. 1877.
Cutaneous and Venereal Memoranda. By Henry G. Piffard, A.M., M.D., Prof,
of Dermatology Univ. of City of New York, and George Hexry Fox, A.M., M.D.,
Surg, to N. Y. Dispensary. New York : William Wood & Co., 1877.
Diseases of the Nervous System : their Prevalence and Pathology. By Julits
Althaus, M.D., M.R.C.P. Lond., Sen. Phys. to Hosp. for Epilepsy andParalysis, etc.
New York : G. P. Putnam's Sons, 1878.
A Series of American Clinical Lectures. Vol. III., No. V. Points in the Diacnrois
of Hepatic Affections. Bv E. G. Jaxewat, M.D. New York : G. P. Putnam's Son-.
1877.
A Compend of Diagnosis in Pathological Anatomy, with Directions for making Post-
mortem Examinations. By Dr. Johaxxes Orth, First Assist, in Anatomy at Patho-
logical Institute in Berlin. Translated by Frederick Cheever Shattuck, M.D.,
and George Kraxs Sabixe, M.D. Revised by Regixal Hebei: Fitz. M.D. With
numerous additions from MS. prepared by the Author. New York : Hurd & Hough-
ton, 1878.
Public Hygiene in America. Being the Centennial Discourse delivered before the
International Medical Congress, Philadelphia, September, 1876. By Hexry I. Bow-
ditch, M.D. With extracts from correspondence from the various States. Together
with a Digest of American Sanitary Law. By Hexry G. Pickerixg, Esq. Boston :
Little, Brown <fc Co., 1877.
Outlines of Modern Chemistry, Organic, based in part upon Riches's Manual de
Chimie. By C. Gilbert Wheeler, Prof, of Chemistry in Univ. of Chicago. Chicago :
Jansen, McClurg & Co., 1877.
Pyaemia and Septicaemia. By B. A. Watsox, M.D. New York, 1877.
Circulars of Information of the Bureau of Education. Nos. 1 and 2, 1877. Reports
on the System of Public Instruction. Washington, 1877.
Contributions to the History of Medical Education and Medical Institutions in the
United States of America. 1776-1876. Special Report prepared for the U. S. Bureau
of Education by N. S. Davis, A.M., M.D. Washington, 1877.
The International Conference on Education held at Philadelphia, July 17 and 18, in
connection with the International Exhibition of 1876. Washington, 1877.
Mental Hygiene. By Eugexe Grissom, M.D. Raleigh, 1877.
A Case of Synovial Bursa of the Hyoid Bone. By Clixtox Wagxer. M.D.
Columbus, 1877.
Early Syphilis in the Negro. By I. Edmoxdsox Atkixsox, M.D. Baltimore.
Pathology and Treatment of Sprains. By Richard O. Cowlixg, M.D. Louisville.
1877.
The Sanitary Condition of Portland. By Frederic Hexry Gerrish, M.D. Port-
land, 1877.
Treatment of Diphtheria. By E. N. Chapmax, M.D. Buffalo, 1877.
The Safety of Ships and of those who Travel in them. By Johx M. Woodworth,
M.D. Cambridge. 1877.
Catalogue of the Alumni of the Medical Department of the Universitv of Pennsyl-
vania. 1765-1877. Philadelphia, 1877.
Sycosis. By A. R. Robixsox, M.B., L.R.C.P. and S. Edin., Special Pathologist to
New York City Asvlum for the Insane. New York, 1877.
Pompholyx. By A. R. Robixsox, M.B. New York, 1877.
The Strumous Element in the Etiology of Joint-Disease, from an Analysis of Eight
Hundred and Sixty Cases. By V. P. Gibxey, M.D., Assist. Surg, to Hospital for the
Ruptured and Crippled, N. Y. New York, 1877.
Physicians' Prescription Blank-Book. Cincinnati : Robert Clarke & Co., 1875.
Physicians' Case-Record Ledger. Cincinnati : Robert Clarke <fc Co., 1877.
Physicians' Pocket Case-Record. Cincinnati : Robert Clarke <fc Co., 1S77.
Lead-Poisoning in Frogs. By Johx J. Masox, M.D., New York. New York, 1877.
Moral Insanity. By H. M. BaxxisteR, M.D. Chicago, 1877.
The Relations existing between Eczema and Psoriasis. Bv Robert Campbell,
M.D. New York, 1877.
The Causes and Geographical Distribution of Calculous Diseases. Bv Claudius H.
Mastix, M.D., of Mobile, Ala. Philadelphia, 1877.
TO READERS AND CORRESPONDENTS.
9
Origin and Progress of Medical Jurisprudence. 1776-1876. By Stanford E.
ChaimJ, A.M., M.D. Philadelphia, 1876.
The Patholoay and Treatment of Morbus Coxarius. By Lewis A. Sayre, M.D.
Philadelphia, 1877.
The Virus of Venereal Sores : its Unity or Duality. By Freeman J. Bumstead,
M.D. Philadelphia, 1877.
Variations in Type and in Prevalence of^Diseases of the Skin in Different Countries
of Equal Civilization. By James C. White, M.D. Philadelphia, 1877.
The Nature, Origin, and - Prevention of Puerperal Fever. By W. T. Lusk, M.D.
Philadelphia, 1877.
The General Subject of Quarantine, with particular reference to Cholera and Yellow
Fever. By John M. Woodworth, M.D. Philadelphia, 1877.
Ovariotomy by Enucleation. By Julius F. Miner, M.D. Philadelphia, 1877.
Typical Case of Addison's Disease, with Remarks. By George Ross, A.M., M.D.
Montreal, 1877.
Excision of the Knee-Joint. By George E. Fenwick, M.D. Montreal, 1877.
Cephalic Version by the External Bi-Polar Method. Arrest of Profuse Post-Partum
Hemorrhage with Tincture of Iodine. By Jno. S. Coleman, M.D., Augusta, Ga.
Now York, 1877.
The Development of the Middle Ear. The Obstetric Forceps. By David Hunt, M.D.
Report of a Successful Case of Cesarean Section after Seven Days' Labour, with
some Comments upon the Operation. By David W. Jenks, M.D. New York, 1877.
Stricture of the Urethra. AVhen and how shall we perform Urethrotomy ? By
Cl vudius H. Mastin, M.D., LL.D., Mobile, Ala. Louisville, 1877.
What Anesthetic shall we Use? By Julian J. Chisolm, M.D. Baltimore, 1877.
The Narcotic Effect of Morphia on the New-Born Child, when Administered to the
Mother in Labour. By Walter R. Gillette, M.D. New York, 1877.
Address in Mental Disorders before the Medical Society of the State of Pennsylvania.
By John Curwen, M.D. Philadelphia, 1877.
Case of Unilateral Cerebellar Abscess and Tumours without Persistence of Symp-
toms. By C. H. Hughes, M.D.
The Influence of Alcohol. By Wm. M. Compton, M.D.
Clinical Lectures on Surgery. Lecture I. By J. H. Poolet, M.D. Columbus, 1877.
Relation of Moisture in Air to Health and Comfort. By Robert Briggs. Phila-
delphia, 1877.
A Case of Ovarian Dropsy simulating Ovarian Tumour. By Theodore A. McGraw,
M.D. New York, 1877.
Transactions of the International Medical Congress of Philadelphia, 1876. Edited
for the Congress by John AsHhurst, Jr., M.D. ^Fellow of the College of Physicians
of Philadelphia, etc. Philadelphia, 1877.
Public Health Reports and Papers. Vol. III. Presented at the meetings of the
American Public Health Association in the years 1875-76. With an Abstract of the
Record of Proceedings, 1876. New York : Hurd & Houghton, 1877.
Transactions of the Canada Medical Association, 1877. Montreal, 1877.
Transactions of the Medical Association of the State of Alabama, 1S77. Mont-
gomery, 1877.
Transactions of the Medical Association of Georgia, 1877. Atlanta, 1877.
Transactions of the Medical Society of the State of North Carolina, 1877. Salem,
1877.
Transactions of the New Hampshire Medical Society, 1877. Concord, 1877.
Transactions of the NeAv YorkJPathological Society. Vol. Second. Edited by John
C. Peters, M.D., President of MLed. Soc. of County of New York, etc. New York :
Wm. Wood & Co., 1877.
Transactions of the Minnesota State Medical Society, 1877. Saint Paul, 1877.
Proceedings of the Medical Society of the County of Kings, Oct., Nov., Dec, 1877.
Transactions of the Texas State Medical Association, 1877. Marshall, 1877.
Transactions of the Kansas Medical Society, 1877. Lawrence, 1877.
Transactions of the Indiana State Medical Society, 1877. Indianapolis, 1877.
Transactions of the Medical Society of the State of Pennsylvania, June, 1877.
Philadelphia, 1877.
Proceedings of Academy of Natural Sciences of Philadelphia, April to August, 1877.
Report of the Births, Marriages, and Deaths, in the City of Providence, for the year
• 1876. By Edwin M. Snow, M.D., Supt. of Health and City Registrar. Providence,
1877.
Report of the Board of Health of the City of St. Louis. St. Louis, 1877.
Annual Report of the Surgeon-General United States Army, 1877.
Annual Report of the State Board of Health of California for 1876 and 1877.
Sacramento, 1877.
Report of the Wisconsin State Hospital for the Insane. Madison, 1877.
Special Report of the Board of State Commissioners of Public Charities of Illinois.
Springfield, 1877.
Report of the Health Officer of San Francisco for the year ending June 30, 1877.
10
TO READERS AND CORRESPONDENTS.
The following Journals have been received in exchange :—
Deutsches Arcliiv fur Klinische Medicin. Bd. XX., Heft 3, 4.
Archiv der Heilkunde, September, October, 1877.
Centr.alblatt fiir die Medicinische Wissenschaften. Nos. 36-48, 1877.
Allgemeine Wiener Medizinische Zeitung. Nos. 36-49, 1877.
Deutsche Medicinische Wochenschrift. Nos. 36-48, 1877.
Upsala L'akarefb'renings Forhandlin^ar. Bd. XIII., No. 1.
Bibliothek for Lseger. Vol. VII., Heft 4.
Nordiskt Medicinskt Archiv. Bd. IX., Tredje Haftet.
Annali Universali di Medicina e Chirurgia. Settembre, Ottobre, Novembre, 1877.
Giornale Italiano della Malattie Veneree e della Pelle. Ottobre, 1877.
Commentaido Clinico di Pisa. Agosto, Settembre, Ottobre, 1877.
L'Imparziale. Nos. 17, 18, 19, 21, 22, 1877.
Lo Sperimentale. Fascic. 9, 10, 11, 1877.
O Correio Medico de Lisboa. Nos. 15, 16, 17, 18, 1877.
Cronica Medico-Quirargica de la Habana. Settembre, Oct., Dec, 1877.
Gaceta Cientifica de Venezuela, 1877. Nos. 9, 10, 11.
Archives Generales de Medecine. Oct., Nov., Dec, 1877.
Annales de Dermatologie et de Syphiligrapbie. T. VIII., No. 5. »
Annales des Maladies de l'Oreille et du Larynx. Nov. 1877. .
Revue des Sciences Medicales en France et de l'Etranger. Octobre, 1877.
Revue Mensuelle de Medecine et de Chirurgie. Septembre, Oct., Nov., 1877.
Gazette Hebdomadaire de Medecine et de Chirurgie. Nos. 37-49, 1877.
L'Union Medicale. Nos. 106-144, 1877.
Le Progres Medical. Nos. 36-49, 1S77.
Le Mouvement Medical. Nos. 36-48, 1877.
L' Anne 3 Medicale. Nos. 10,11, 12, 1877.
Revue Scientifique de la France et de l'Etranger. Nos. 10-23, 1877.
Union Medicale et Scientifique du Nord-Est. Sept., Oct., Nov., 1877.
The Retrospect of Medicine. Jan. to June, 187 7.
The British and Foreign Medieo-Chirurgical Review. July, Oct., 1877.
The Lancet. July, Aua'., Sept., Oct., Nov., Dec, 1377.
The Medical Times andTGaz -tte, July, Aug., Sept., Oct., Nov., Dec, 1877.
The British Medical Journal. July, Aug.~ Sept., Oct., Nov., Dec, 1877.
The Medical Examiner. July, Aug., Sept., Oct., Nov., Dec, 1877.
The London Medical Record. July, Aug., Sept., Oct., Nov., Dec, 1877.
The Sanitary Record. July, Aug., Sept., Oct., Nov., Dec, 1877.
The Practitioner. July, Aug., Sept., Oct., Nov., Dec, 1877.
The Obstetrical Journal of Great Britain. July, Au«;., Sept., Oct., Nov., Dec, 1877.
The Journal of Anatomy and Physiology. July, October, 1877.
Edinburgh Medical Journal. July, August, September, October, 1877.
The Glasgow Medical Journal. July, October, 1877.
The Dublin Journal of Medical Science. July, Dec, 1877.
The Doctor. June, September, October, 1877.
The Indian Medical Gazette. June, July, Aug., Sept., Oct., Nov., 1877.
The Australian Medical Journal. Jan., Feb., March, April, 1877.
The Australian Practitioner, Oct. 1877.
Canada Medical and Surgical Journal. July, Aug., Sept., Oct., Nov., Dec, 1877.
The Canada Medical Record. June, July, August, Sept., Oct., Nov., 1877.
The Canadian Journal of Medical Science. July, Aug., Sept., Oct., Nov., Dec, 1877.
The Canada Lancet. July, Aug., Sept., Oct., Nov., Dec, 1877.
L'Union Medicale du Canada. Juillet, Aout, Septembre, Oct., Dec, 1877.
The usual American exchanges have been received ; their individual acknowledg-
ment is omitted for want of space.
Communications intended for publication, and books for review, should be sent
free of expense, directed to Isaac Hats, M.D., Editor of the American Journal of the
Medical Sciences, care of Mr. Henry C. Lea, Philadelphia . Parcels directed as above,
and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 King
William Street, Charing Cross, London, will reach us safely and without delay.
All remittances of money and letters on the business of the Journal should be ad-
dressed exclusively to the publisher, Mr. H. C. Lea, No. 706 Sansom Street.
The advertisement sheet belongs to the business department of the Journal, and all
communications for it must be made to the publisher.
CONTENTS
OF
THE AMERICAN JOURNAL
OF
THE MEDICAL SCIENCES.
NO. CXLIX. NEW SERIES.
JANUARY, 1878.
ORIGINAL COMMUNICATIONS,
MEMOIRS AND CASES.
ART. PAGE
I. On Mountain Fever and Malarious Waters. By Charles Smart, M.B.,
CM., Captain and Assistant Surgeon, U. S. Army. . . . .17
II. Tattooing as a means of Communicating' Syphilis ; an Investigation of
Twenty-two Cases exposed to Inoculation with the Virus of Mucous
Patches, in Fifteen of Avhich Syphilis followed. By F. F. Maury, M.D.,
Lecturer on Venereal Diseases at the Jefferson Medical College, Attending
Surgeon to the Philadelphia Hospital; and C. W. Dulles, M.D., late
Interne at the Philadelphia Hospital. . . . . . .44
III. Disease of the Sacro- Iliac Synchondrosis. By Charles T. Poore, M.D.,
Surgeon to St. Mary's Free Hospital for Children, and to Charity Hospi-
tal, New York 62
IV. Action of Iron, Cod-liver Oil, and Arsenic on the Globular Richness of
the Blood. By Elbridge G. Cutler, M.D., and Edward H. Bradford,
M.D., of Boston ■ . .74
V. A Contribution to the Study of Subconjunctival Serous Cysts. By
Charles S. Bull, M.D., Surgeon to the New York Eye Infirmary and to
Charity Hospital. ........... 85
VI. The Distribution of Nerves in the Iris. By Henry F. Formad, B.M.,
M.D., of Philadelphia. (Abstract from an Inaugural Prize Essay, pre-
sented to' the Medical Faculty of the University of Pennsylvania.) . . 93
VII. A Case of Ovariotomy during Subacute Peritonitis and Suppuration of
the Cyst following Aspiration; with Remarks. By Paul F. Mund6,
M.D., Assistant Surgeon to the New York State Woman's Hospital. .- 100
VIII. On the Duties and Responsibilities of General Practitioners towards
Melancholies and Suicides. By A. O. Kellogg, M.D., of the Hudson
River State Hospital, Poughkeepsie, New York. . . . . .109
IX. Acute Inflammation of the Middle Ear; Destruction and Reproduction
of the Entire Membrana Tympani. By Leartus Connor, M.D., Professor
of Physiology and Clinical Medicine in Detroit Medical College, . .114
X. Lithotrity hy a Single Operation. By Henry J. Bigelow, M.D., Pro-
fessor of Surgery in Harvard University, and Surgeon to the Massachusetts
General Hospital. . . . . . . . . . . .117
12
CONTEXTS.
ART. PAGE
XI. Case of Dislocation of the Hip upwards and forwards on the Pubes, of
Twenty-six Davs' Standing, successfully reduced : followed bv Complete
Recovery. By M. H. Henry, M.A., M.D., Surgeon-in-Chief of the
State Emigrant Hospitals, Ward's Island, New York, etc. etc. . .134
XII. Epithelioma Laryngis ; Final Removal by Laryngo-thyrotomy. By
S. H. Chapman, A.M., M.D., of New Haven, Conn. . * . . .186
XIII. Bromide of Potassium in the Uncontrollable Vomiting of Pregnancy.
By Samuel C. Busey, M.D., Washington, D. C, President of the Medical
Society of the District of Columbia 140
XIV. Case of Paralysis of Abductors of Vocal Cords ; Tracheotomy ; Re-
covery ; Relapse; Death. By Andrew H. Smith, M.D., Surgeon to the
Throat Department of the Manhattan Eye and Ear Hospital, New York. 14.3
XV. Case of Molluscum Fibrosum ; Tubercles of an Unusual Size. By F.
Peyre Porcher, M.D., Professor of Clinical Medicine and of Materia
Medica and Therapeutics in Medical College of State of South Carolina,
Charleston. ............ 145
XVI. A Case of Membranous Entero-Colitis. By W. F. Muhlenberg,
M.D., of Reading, Pennsylvania. . . . . '. . . .146
XVII. Two Cases" of Nerve Stretching. By Thomas G. Morton; M.D.,
Surgeon to the Pennsylvania Hospital. Reported by William C. Cox,
M.D., Assistant Surgeon to Philadelphia Orthopaedic Hospital, and Sur-
geon to Out-Department of the Pennsylvania Hospital. . . . .150
XVIII. Use of the Testicle in the Radical Cure of Inguinal Hernia. By
Charles T. Hunter, M.D., Demonstrator of Surgery- in the University of
Pennsylvania. . . . . . . . . . . .152
XIX. A Case of Purulent Pelvic Effusion, opening spontaneously into the
Vagina. By W. H. Haynes, M.D., Late Resident-Physician to the
Presbyterian Hospital ; Attending Physician to the Eastern Dispensary,
New York " 153
REVIEWS.
XX. Transactions of the International Medical Congress of Philadelphia.
1876. Edited for the Congress by John Ashhurst, Jr., A.M., M.D.
Royal 8vo. pp. xlix., 1153. Philadelphia, 1877. . . . .155
XXI. The Ear : its Anatomy, Physiology, and Diseases. A Practical
Treatise for the use of Medical Student-: and Practitioners. By Charles
H. Burnett, A.M., M.D., Aural Surgeon to the Presbyterian Hospital,
etc. With eighty-seven illustrations. Svo. pp. GIG. Philadelphia:
Henry C. Lea, 1877 173
XXII. Forensic Medicine and Toxicology. By W. Bathurst Woodman,
M.D., F.R.C.P., Assistant-Physician to* the London Hospital, etc. etc..
and Charles Meymott Tidy, M.B., F.C.S., Professor of Chemistry and of
Medical Jurisprudence and Public Health at the London Hospital, etc.
etc. Svo. pp. 1083. Philadelphia: Lindsay & Blakiston, 1877. . . 181
XXIII. Fat and Blood ; and How to Make Them. By S. Weir Mitchell,
M.D., Member of +he National Academy of Sciences, etc. 12mo. pp.
101. Philadelphia: J. B. Lippincott & Co., 1877. . . . .192
ANALYTICAL AND BIBLIOGRAPHICAL NOTICES.
XXIV. Saint Thomas's Hospital Reports. New Series. Edited by Dr.
Bristowe, Dr. John Harley, and Mr. Wagstaffe. Vol. VII. 8vo. pp.
xiv., 392. London: J. & A. Churchill, 1876 199
XXV. Medico-Chirurgical Transactions. Published by the Royal Medical
and Chirurgical Society of London. Second series. Volume xli. 8vo,
pp. lxvi., 430. London: Longmans, Green, Reader & Dyer, 1876. . 207
CONTENTS.
13
APT. PAGE
XXVI. Public Health Reports, and Papers presented at the Meetings of
the American Public Health Association in the years 1875-1876, with an
Abstract of the Record of 'Proceedings, 1876. Vol. III. 8vo. pp. 241.
New York: Hurd & Houghton. 1877. 213
XXVII. Surgical Observations on Gunshot "Wounds of the Hip-joint. By
B. Von Langenbeck, Professor of Surgery in the University of Berlin,
etc. etc. Translated by James F. West, F.R.C.S., Senior Surgeon to
the Queen's Hospital, and formerly Professor of Anatomy in Queen's
College, Birmingham. 8vo. pp. viii., 63. Birmingham: White & Pike,
1876. . . . . 219
XXVIII. Retarded Dilatation of the Os Uteri in Labour. By Albert H.
Smith, VI. D., Lecturer on Obstetrics to the Philadelphia Lying-in Charity.
18mo. pp. 46. Philadelphia. 187 7 , . . 224
XXIX. A Clinical Guide to the Diagnosis. Treatment, and Prevention of
Venereal Diseases. By S. Engelsted, M.D., Physician-in-chief to the
City Hospital and Clinical Teacher at the University of Copenhagen.
8vo. pp. 489. Copenhagen (Denmark) : Reitzel, 187 7. . . . . 228
XXX. Cyclopaedia of the Practice of Medicine. Edited by Dr. H. Von
Ziemssen, Professor of Clinical Medicine in Munich, Bavaria. Vol. XVI.
Diseases of the Locomotive Apparatus, and General Anomalies of Nutri-
tion. By Prof. H. Senator, of Berlin; Prof. E. Seitz, of Giessen :
Prof. H. Immermann, of Basel; and Dr. Birch-Hirsehfeld, of Dresden.
Albert H. Buck, VI. D., of New York, editor of American edition. 8vo.
pp. xii.. 10G0. New York : William Wood & Co., 1877. . . .235
XXXI. The Toner Lectures Instituted to Encourage the Discovery of Xew
Truths for the Advancement of Medicine, Lecture V. On the Surgical
Complications and Sequels of the Continued Fevers. By William W.
Keen, M.D. , of Philadelphia. Delivered February 1 7, 1876. Washing-
ton: Smithsonian Institution. April, 1877. . . . . . .236
XXXII. The Cure of Rupture, Reducible and Irreducible, also of Varico-
cele and Hydrocele, by new methods. By George Heaton, M.D. Ar-
ranged by j. H. Davenport, M.D. 12mo. pp. -196. Boston: H. O.
Houghton & Co., 1877. . . . 238
XXXIII. On Hare-lip and Cleft Palate. By Francis Mason, F.R.C.S.,
Surgeon and Lecturer on Anatomy at St. Thomas's Hospital, etc. With
sixty-six illustrations. 8vo. pp. viii., 134. London: J. & A. Churchill,
1877 . . . . . . .239
XXXIV. Circular Orders Xo. 3, War Department, Surgeon-General's
Office, August 20, 1877. Report on Lister's System of Wound Treat-
ment. By Assistant- Surgeon Alfred C. Girard, U. S. A. pp. 12. . 240
XXXV. Illustrations of Clinical Surgery. By Jonathan Hutchinson, F.R.
C. S., etc. Fasciculus VII. Folio, pp. 143-172. Philadelphia: Lindsay
& Blakiston, 1877 .241
XXXVI. Lectures on Fevers. By Alfred L. Loomis, A.M., M.D., Prof,
of Pathology and Practical Medicine in the Medical Department of the
University of the City of Xew York. 8vo. pp. xii., 403. Xew York:
William Wood & Co.,' 1877 241
XXXVII. A Guide to Therapeutics and Materia Medica. By Robert Far-
quharson, M.D. Edin., Lecturer on Materia Medica, at St. Mary's Hos-
pital Medical School. Enlarged and Adapted to the U. S. Pharmacopoeia.
by Frank AVoodbury, M.D. "Philadelphia: Henry C. Lea, 1877. . . 243
XXXVIII. Hospitals : their History, Organization, and Construction.
■ Boylston Prize Essay of Harvard University for 1876. By W. Gill
Wvlie, M.D. 8vo. pp. 240. Xew York : D. Appleton & Co.", 187 7. . 244
XXXIX. Lectures on Practical Surgery. By H. H. Toland, M.D., Prof
of Principles and Practice of Surgery and Clin. Surg, in Med. Dept of
University of California. 8vo. pp. xii., 508. Philadelphia : Lindsay &
Blakiston, 187 7 245
14
C O N T E X T S .
ART. PAG K
XL. > The Morphology of the Skull. By W. K. Parker, F.R.S., Hun-
terian Prof, at Royal College of Surgeons, and G. T. Bettany, M.A.,
B.Sc., etc. pp. 368. London: Macniillan & Co., 1877. . . . 247
XLI. An Index of Diseases and their Treatment. By Thomas Hawkes
Tanner, M.D., F.L.S. Second Edition. Revised by W. H. Broadbent,
M.D., F.R.C.P., Phys. to the London Fever Hospital, etc. 8vo. pp.
xxx., 432. Philadelphia: Lindsay & Blakiston, 1877. .... 247
XLI1. The Fourth Annual Report of the Board of Health of the City of "
New Haven, 1876. 8vo. pp. 64. New Haven, 1877 248
QUARTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.
Anatomy and Physiology.
PAGE j PAGE
The Acidity of the Human Gastric Juice in a Case of Gastric Fistula.
By M. Richet 249
Materia Medica and Therapeutics.
On Hvdrobromic Acid. Bv Mr.
T. F. Abraham. . . .250
On Phosphate of Lime. By MM.
Paquelin and Jolly. . . . 250
Transformation of Salicylic Acid.
By M. Byasson. . . .250
Mode of Action of Anaesthetics.
By Prof. Binz 251
Action of Pilocarpin on the Eye.
By M. Galezowski. . . . 252
Sulphate of Atropia in Pathological
Sweating. By M. Royet. . 252
Medicine.
The Excretion of Indican and
Lime in Disease. By Prof.
Senator. ..... 253
Diminution of the Acidity of the
Gastric Juice in Febrile Condi-
tions. Dr. Von den Velclen. . 254
Salicine in Rheumatism. By Mr.
Samson Gemmell and Mr. Frank
Shearer. . . . . .255
Etiolooy of Typhoid Fever. Bv
M. Ch. Bouchard. . . 255
Diphtheria complicating Enteric
Fever. By Dr. Greenfield. . 256
The Therapeutics of Diphtheria.
By Mr. J. Graham Brown. . 257
On the Use of Iron in Epilepsy.
By Dr. W. R. Gowers. . .257
Treatment of Croup. By Dr. S.
Oldoini 258
The Etiology of Pneumonia. By
Dr. Bernhard Heidenhain. . 258
Cold Washings and Douches in
Tuberculosis. By Dr. Pogacnik. 259
The Use of Digitalis in Disease of
the Aortic Valves. By Dr. J.
Milner Fothergill. . . . 260
Complete Obliteration of the Aorta.
By Dr. Wickham Legg. . . 260
Treatment of Neurosis of the Sto-
mach. By Dr. H. Lebert. . 261
Case of Obstruction of the Bowels
by a Dislocated Spleen. By Dr.
Victor Babesiu. . '. . 262
Localized Peritoneal Exudation
which Perforated the Lung and
Simulated Pyojmeumothoi'ax.
By Dr. Pfahl 262
CONTENTS.
15
PAGE
Iodic Purpura. By Prof. A.
Fournier. ..... 263
Molluscum Contagiosum. By
Kaposi. . . . . .265
Lichen Ruber Acuminatum and
Lichen Ruber Planus. By
Kaposi. . . . . . 265
On Zoster Recidivus. By Kaposi, 266
PAGE
Acetic Acid in Psoriasis. By Dr.
Jansen " .266
On Cysticerci in the Skin. By
Guttmann 266
'On (Edema and the Lymph -stream
in Inflammation. By Dr. O.
Lassar .266
Surgery.
On the Treatment of Ranula. By
Dr. Panas. . . . .268
Extirpation of the Larynx. By
Dr. David Foulis. . . .268
Gastroraphy. By' Prof. Billroth. 271
Extirpation of Spleen for Rapid
Hypertrophy. By Mr. H. L.
Browne. . . . . .272
Two Peculiar Varieties of Hydro-
cele of the Cord. By Mr. Fur-
neaux Jordan. . . . .273
Treatment of Blennorrhagic Epi-
didymitis with Iodoform Oint-
ment. By Dr. Alvares. . .273
Carbolized Catgut Ligature. By
Mr. Bryant 273
Aneurism of the Aorta, Innominate,
Subclavian, and Carotid Arteries
successfully treated by Double
Distal Ligature. By Mr. Rich-
ard Bar well. . . . .275
Ligature of the Common Carotid
Artery in Cases of Injury of the
External Carotid. By Dr. Giu-
seppe Ruggi. . . . .277
Diagnostic Value of Pulsation, a
propos of a Case of Pulsating
Tumour of the Upper End of the
Left Tibia. By Prof. Pasquale
Laudi. . ... . . 278
Sarcoma . of the Median Nerve ;
Resection without Disturbance of
Sensation. By Kraussold. . 279
Ophthalmology and Otology.
Sclerotomy in Glaucoma. By i On Acute Cellulitis of the Orbit.
Prof. L. Mauthner. . . .280 By Dr.. Sonnenburg. . . 281
Drainage of the Eye in Cases of On the Treatment of Suppurative
Detached Retina. By Dr. Her- Otitis by Drainage of the Exter-
mann Cohn. . . . 281 nal Auditory Meatus. By Dr.
Guyon. . . . .283
Midwifery and Gynaecology.
On the Investigation of the interior
of the Uterus by the Carbolized
Hand at long Intervals after De-
livery. By Dr. J. Matthews
Duncan. . . . . .284
The Septic Influence of Lochial
Discharge. By Prof. Kehrer. . 285
Mammary Abscess treated Anti-
septically. By Dr. James Car-
michael 286
On the Bearings of Chronic Disease
of the Heart upon Pregnancy and
Parturition. By Dr. Angus
Macdonald 287
On Abnormal Softness of the Nulli-
parous Uterus, as a Factor in
the Etiology of Uterine Distor-
tions, and as a Cause of Impair-
ment of Power of Locomotion.
By Dr. Graily Hewitt. . .288
Ovariotomy during the Course of
Acute Peritonitis. By Dr. Law-
son Tait. . . . - .289
Medical Jurisprudence and Toxicology.
Acute Poisoning by Acetate of
Copper. By Messrs. Feltz and
Bitter 290
Toxic Properties of Dynamite.
M. Bruet.
Bv
!90
16
CONTENTS.
AMERICAN INTELLIGENCE.
Original Communications.
PAGE
A Case of Fracture of the Body of
the Scapula. By E. T. Easier.
A.M., M.D.
Arkansas.
of Little Bock,
251
Menstruation and Ovulation
Dr. T. Gaillard Thomas. .
Brief Study of the Hundred Cases
of Menstruation. By Dr. The-
ophilus Parvin.
Localization of Diseased Action in
Domestic Summary
. Bv
292
203
the (Esophagus. By Dr. Harri-
son Allen. . . . . 29o
Relation of the Urftiary Organs to
Puerperal Diseases. By Dr. W.
M. Chamberlain. . * . . 294
The Post-mortem Imbibition of
Poisons. By Dr. Reese. . . 294
ERRATUM.
In the number for October, 1877 —
Page 404, line 6, and page 405, line 16, for " Schultze" read li Schelske."
THE
AMEKICAN JOURNAL
OF THE MEDICAL SCIENCES
FOR JANUARY 1878.
Article I.
On Mountain Fever and Malarious Waters. By Charles Smart,
M.B., CM., Captain and Assistant Surgeon, U. S. Army.
In the Rocky Mountain region of this country there prevails a fever to
which the vox populi has attached the name of mountain fever. Igno-
rance of the nature of disease has no doubt fitted this name on many a case
to which a little medical knowledge would have applied a more specific
title. The writer, for instance, has been called' to a case of mountain fever
which proved, on examination, to be one of pneumonia. Such mistakes
are natural. But, within narrower limits, this looseness of diagnosis is
not confined to the non-professional mind. Whether we have an endemic
disease in these mountain regions, separate and distinct from the diseased
conditions which are recognized by the profession elsewhere, is a question
which many a practitioner, who has seen mountain fever, would hesitate
before answering. The first object of this paper will be to attempt a set-
tlement of this point.
In the days of the pioneers and prospectors of this western country,
mountain fever was more common and deadly than it is now. This is
popular testimony, and would weigh but little were it not corroborated by
professional observation at later dates. Severe cases of mountain fever
were of frequent occurrence among the emigrants who crossed the country
on their way to California or the Mormon settlements.1 And the record
of these past attacks appears in practice at the present time. An investi-
gation of previous history, as in life insurance examinations, will often
1 Dr. Williamson, in the discussion on Mountain Fever. Salt Lake Medical Society,
March 12, 1877.
No. CXLLX Jan. 1878. 2
18
Smart, Mountain Fever and Malarious Waters.
[Jan.
bring forth an account of serious temporary disablement from mountain
fever, either on the overland journey or immediately after arrival in the
mountain country.1 In these earlier days the profession treated this fever
by mercurialization ;2 the laity by the " time-honoured sage tea."3 To
whom belongs the credit of having first attacked it with quinia fails to
appear upon the record.
But, although neither so general nor so dangerous now as when the
emigrants plodded westward with their broken-down stock and overladen
wagons, it appears in a severe form with sufficient frequency to make it a
matter of much interest to the profession, irrespective of the light which
its study seems to throw, as will appear hereafter, on Questions of larger
sanitary import.
The literature of this fever is exceedingly meagre, consisting only of
papers by four medical men and scattered remarks by army medical officers.
In 1851 Dr. C. E. Boyle published an article on " Mountain Fever."4
In the same year Dr. J. E. Oatman presented the subject under the cap-
tion of " Mountain and Malarious Fevers, produced by the same cause."5
In 1855 Dr. Ewing wrote on " Mountain Fever" in the St. Louis Medi-
cal and Surgical Journal ;6 and, lastly, in 18G5, Dr. F. Rice Waggoner,
in the July number of the American Journal of the Medical Sciences,
published an article entitled, " On the Mountain or Continued Miasmatic
Fever of Colorado Territory."
Dr. Waggoner was taught by his pioneer brethren that mountain fever
was a modification of typhoid or enteric fever, but he shows clearly in his
paper that what he looked upon as mountain fever were cases of purely
malarial origin — severe remittents, unremitting remittents, so to speak, or,
as he calls them, continued miasmatic fevers.
Fort Lyon, Colorado, at which Dr. Waggoner treated his cases, was
situated in the valley of the Arkansas River, with thousands of marshy
acres around it, with a summer temperature running as high as 105° F.,
with heavy autumnal rains, and a sick report bristling with intermittent
and remittent fevers. Two years after his article wfas published the post
was abandoned on account of its unhealthy location, and a new site having
been selected on higher ground, about twenty miles distant from the old
one, the garrison was relieved from its liability to this fever.
Dr. Waggoner's paper was written not so much to prove the malarial
origin of the mountain fever of Colorado as he observed it, as to insist on
1 Dr. Benedict, in the aforesaid discussion. Salt Lake City Medical Society, March
12, 1877. ,
2 Dr. Allen Fowler. 3 Dr. Benedict.
* Ohio Medical and Surgical Journal, vol. iii. pp. 528-530 ; and St. Louis Medical
Journal, vol. ix. pp. 454-456.
* North Western Medical and Surgical Journal, vol. viii. pp. 105-108; and Boston
Medical and Surgical Journal, vol. xliv. pp. 511-512.
s Vol. xiii. pp. 109-116.
1878.] Smart, Mountain Fever and Malarious Waters. 19
large doses of quinia in its treatment — sixty to seventy-five grains in
divided doses during the twenty-four hours. This treatment, however,
has been practised by army medical officers in the fever districts of the
Gulf coast, the southern States, and western territories since the days of
the Florida war.1
But, if Dr. Waggoner found his cases to be so clearly malarial, those of
Dr. J. E. Oatman were apparently met with under different circumstances,
if we may judge from the title of his article — " Mountain and Malarjous
Fevers, produced by the same cause." There must have been some doubt
as to the cause to call forth the argument. I regret that I have been un-
able to lay hands on the articles written by Drs. Oatman, Ewing, and
Boyle.
To come to more recent dates, I find in the Report on the Hygiene of
the United States Army, published in 1875, that various medical officers
take cognizance of mountain fever.
Surgeon E. P. Vollum, IT. S. A., my predecessor at this post, Camp
Douglas, Utah, reports2 that : " About once in ten years an epidemic of
mountain fever appears to a considerable extent throughout the Rocky-
Mountain regions including Utah. Its last appearance was in the fall and
Avinter of 1871-72. It is a malarial fever, commencing as an intermittent,
passing on to a remittent, then into a typhoid condition. It may often be
cut short by prompt large doses of quinia, but after the typhoid symptoms
set in it should be regarded as typhoid fever and so treated. The mor-
tality is often high, but reduced in proportion to the attention a patient
receives in the early stages."
The register of the undertaker of Salt Lake City, as quoted by Dr.
Yoilum himself,3 does not bear out his statement as to its occasional epi-
demic virulence, for the percentage of deaths from fever to deaths from all
causes —
for 1871 was 11.33
" 1872 " 10.24
" 1873 " 13.20
" 1874 " 12.46
showing, at least, that if mountain fever visited the city in 1871-72 to a
greater extent than in the two following years, it failed to leave its mark
on the undertaker's books.
Dr. A. J. Hogg, from Medicine Bow, Wyoming Territory, reports* that:
" Occasionally there is a case of a fever vaguely called mountain fever,
but which resembles the remittent type more than any other, and is very
amenable to treatment."
1 For many reports on this head see Medical Statistics U. S. Army, 1839-55, pp. 637-
690.
2 Page 340. Report on Hygiene of the U. S. Army, 1875.
3 Page 341. Ibid. 4 Page 361. Ibid.
20 Smart, Mountain Fever and Malarious Waters. [Jan.
Assistant Surgeon Patzki, at Fort Steele, Wyoming Territory, reports1
that —
" A remittent fever, occasionally very severe, is met with, by the mountaineers
called mountain fever, and much dreaded by them. The most prominent symp-
toms are headache, severe aching through the whole body, insomnia, furred tongue,
frequent, full pulse, constipation. Chills are infrequent. The efficacy of large
doses of quinine proves the malarial origin. The mountaineers treat it with their
panacea, sage tea, and, as they assert, quite successfully. Men cutting timber
along the streams, mostly Danes and Swedes, sutler most from this fever."
Surgeon F. L. Town, U. S. A., at Fort Shaw, Montana, states5 that : —
"Remittent and typho-malarial, and, probably, enteric fjevers, are not infre-
quent in the spring and fall, especially among miners and hunters, or persons who
are generally without shelter ; these, in the parlance of the country, are called
'mountain fevers' indiscriminately. Three cases of typho-malarial fever have
occurred at the post, two of citizens and one a soldier, and with a fatal terini na-
tion in each instance."
Lastly, Assistant Surgeon Jaquette, U. S. A., at Fort Boise, Idaho,
reports3 "an occasional case of fever, either remittent or intermittent, com-
monly called in this country mountain or typho-malarial fever."
Dr. Williamson, of Salt Lake City,4 while admitting the resemblance
to malarial remittent, and the efficacy of quinia, when administered early
in the disease, feels confident, from an extended experience, that if the
fever has fairly established itself before the patient is seen, " you will have
a case of disease that will run from three to five weeks before you can see
the commencement of convalescence."
Dr. Allen Fowler's experience5 has led him to abandon the name of
" mountain fever." The disease to which he formerly applied that title
he now recognizes as malarial remittent fever.
From the above extracts it will be seen that the published testimony in-
dicates the mountain fever of popular parlance as consisting of malarial
remittents with a possibility of typho-malarial or typhoid fevers — that is to
say, that we have no specific fever indigenous to the Rocky Mountain
regions.
But before discussing this conclusion I desire to place on the record the
result of my own observations during a service of nearly four years in the
Rocky Mountains.
I arrived at the post of Fort Bridger, Wyoming Territory, in August, 1 873,
and as the summer was far advanced, expected to come into immediate
contact with the mountain fever or malarial remittent of which I had heard
much and read but little. Yet there seemed nothing malarious in the sur-
roundings of the post. The drainage was good, the valley fall being so
marked as to prevent all stagnation of surface or subsoil water; the vege-
tation scanty, consisting of sage brush and interspersed grass tufts on the
1 Page 385. Report on Hygiene of U. S. Army, 1875.
2 Page 434. Ibid. 3 Page 460. Ibid.
4 Discussion on Mountain Fever. Salt Lake City Medical Society, March 12, 1877.
5 Ibid.
1878.] Smart, Mountain Fever and Malarious Waters.
21
mesas, and a thin belt of shrubby growth along the creek; while the ther-
mometer fell to 32° F. ten months out of the twelve, and the winds blow-
ing most of the time from the northwest, came from the higher peaks of
the Wasatch range. ^
The autumn and winter came and went without the advent of any fever
cases either among the troops or the settlers in the vicinity, and I began to
consider mountain fever a myth. But as spring advanced a few anomalous
cases presented themselves at surgeon's call. The men complained that
they had caught cold, and investigation showed the presence of a slight
catarrh or of some equally slight congestion of the fauces; a local affection
of too trivial a nature to account for the peculiar coexisting constitutional
disturbance. The bowels were constipated, urine scanty, skin dry, com-
plexion sallow, pulse about a hundred, and temperature slightly increased,
with loss of appetite and nausea, much languor and depression of spirits,
pains in the bones and muscles, and stiffness in the joints. Occasionally
instead of constipation there would be a marked looseness of the bowels.
Not that there was anything peculiar in the symptoms as above enumerated,
they simply indicated the febrile condition ; but the languor, the muscular
pains and articular stiffness were more prominent in the appearance and
complaints of the men than the condition of the pulse would have led one
to expect. Some thought they were going to be laid up with rheumatism.
Many had been ailing for a week or two before they reported as sick, the
first signs of deteriorated condition being loss of appetite, disturbed and
dreamful sleep, and morning stiffness in the joints, chiefly the metacarpo-
phalangeal and phalangeal. But if anything could be called characteristic
of this condition it was the appearance of the tongue, smooth and coated
with a thin film like the faint bluish-white advance of the skin over a
healthy ulcer in its progress to cicatrization ; this, with or without a yellow
far toward the base. As I had often seen this tongue connected with ma-
larial poisoning (it was pointed out to me by Dr. R. C. Stiles, then Sur-
geon U. S. Vols.), and as in the more aggravated of these cases remissions
and exacerbations of the febrile state were readily discoverable, I treated
them from the first with quinia, with or without cathartics according as
the film on the tongue was clean or yellow-furred, and returned them to
duty in a few days.
I felt satisfied that the febrile action was totally unconnected with the
slight local congestion — that the latter was in fact an accidental circum-
stance engrafted by simple exposure on a depraved constitution, and en-
grafted the more readily on account of that depraved condition.
The cause of this deterioration in the health of the command was diffi-
cult to unearth. The men were cleanly, well fed, well housed and clothed,
and had just enough of fatigue duty to keep them in healthy condition.
Nor did the sutler's store seem to be implicated in the matter, for men
well known to be temperate were affected as frequently as those whose
22 Smart, Mountain Fever and Malarious Yvraters. [Jan.
reputation in this respect was not so satisfactory. The appearance of the
tongue, the tendency to remission and the influence of quinia seemed to
indicate malarial exhalations as the materies morbi, and yet in view of the
want of malarious surroundings, in view of the season of the year and the
temperature which discountenanced a malarial theory, and especially in
view of the fact that certain recruits who had arrived at the post prostrated
every week or two with intermittent fever were progressing to perfect free-
dom from aguish attacks, I could not bring myself to record these cases
as malarial remittents, but put them down as catarrhs and quinsies, and
awaited developments.
These came in a very short time. Cases appeared of fever without any
complication by local lesion, and I recognized that I must he dealing with
the incipiency of our so-called mountain fever.
At the same time many officers and men in the garrison complained of
feeling out of sorts without reporting sick. They had lost appetite, felt
stupid and sleepy, had pains in the limbs and stiffness in the joints, and th«
tongue was covered with the smooth bluish -white film. To these blue pill
and quinia, or the latter alone, were given, and no more was heard of
them.
The citizens in the neighborhood furnished my first severe case of this
fever. A woman residing near the post, who had been in bed for ten days
under the sage-tea treatment before I was called, seemed beyond the
power of medicine. She was in a typhoid condition, tongue dry and black,
great prostration and emaciation, low delirium, frequent stools of bloody
mucus, followed in a few hours after I first saw her by a state approaching
coma-vigil. Two, weeks later she was convalescing after a course of quinia,
astringents, brandy and nourishment ; but it was long before she recovered
her strength.
Next a surveying party in the neighbourhood of Bridger put into the
post on account of the sickness of two of its members. One had given up
work four or five days, the other two days before their arrival ; but both
had been feeling out of sorts for a long time before they became really
prostrated by their sickness. The latter, the milder or more recent case,
presented the symptoms which I have indicated as affecting the enlisted
men of the garrison, and like them, under quinia, the patient recovered
in a few days: the former differed by having not so much an exaggeration
of the febrile state, as in having more languor and depression of spirits,
with a tongue in which the film had increased in thickness to form a
whitish layer, no yellowish fur being present either at the centre or base.
The case ran a typhoid course of four weeks and was similar in its pro-
gress to that of the woman already mentioned, but as in her case it was not
enteric fever. The exacerbations and remissions were less distinct and
more irregular, the temperature was never so high as in typhoid, the diar-
rhoea was dysenteric in character, and there was no tenderness in the ileo-
1878.] Smart, Mountain Fever and Malarious Waters.
23
crecal region, while for the amount of febrile action as measured by the
pulse and temperature the nervous depression was extreme.
While attending this case I had an opportunity of comparing it with one
of pure typhoid occurring in the person of a girl fifteen years old. This
case was carefully studied, as it was interesting not only in connection with
the mountain fever case, but as bearing upon the origin de novo of typhoid
fever. At its inception it was viewed as another specimen of the mountain
fever, but as it was uninfluenced by quinia, the remedy when pushed pro-
ducing much gastric disturbance and bilious vomiting, the diagnosis was
altered to typhoid, doubtingly, until the eruption established its accuracy.
There were an accompanying bronchitis, evening exacerbations, rose-
coloured eruption, ileo-crecal tenderness, and typhoid diarrhoea, all of which
wrere absent in the mountain fever case.
To complete the fever history of that season and fill the niche between
the incipient cases in the garrison and the typhoid examples among the
citizens, a case occurred in the person of a soldier who was on detail as
post-gardener. Soldiers, when indisposed, appear at surgeon's call for ex-
cuse from duty when, if in civil life, they would not think of sending for
medical advice. Most of the cases in garrison are thus seen at the first
manifestations of the disease ; but this gardener, being his own master and
requiring no excuse from duty, thinking that he would get well in a day or
two, failed to report as sick until the fever was well advanced. His tongue
on admission into hospital was white-coated like that of the surveyor, but
in a week he was convalescing and in two weeks was returned to duty —
thus avoiding the slow convalescence consequent on the development of the
typhoid stage, yet in his case the tongue became dry and its white coating
browned and fissured before the change for the better was inaugurated.
Such having been my experience up to the autumn of 1874, I wrote for
the Report on Hygiene published in 1875, that at Fort Bridger, " a remittent
fever susceptible to the action of quinine is well recognized as being indi-
genous."
While at this same post during the spring and early summer of 1875
and again in the corresponding season of 1876, a recurrence of this febrile
tendency appeared among the troops ; but most of the cases were seen
early, and in a few only did typhoid symptoms begin to make their appear-
ance.
This closes my experience at that station.
One point, however, remains to be mentioned. It is that the records
of the post, the figures left behind them by my predecessors as embodying
their experience of the prevalence of mountain fever, corroborate my own
observations, showing the months of May, June, and July to be the
months of visitation. Thus, during the eight years previous to my assign-
ment, May gave an average of 5. GO cases per thousand of mean strength,
June 13.89, and July 9.47; while no cases were recorded during the
24
Smart, Mountain Fever and Malarious Waters.
[Jan.
months of September and October. Yet Dr. Drake reports those very
months of September and October as the period of maximum prevalence
of malarial fevers in the United States.1
The following table shows the average strength of the command and the
prevalence of this fever in cases per thousand of mean strength : —
Month.
Strength.
Case6.
January
172
4.36
February
. 167
. 75
March .
. 168 *
1.49
April .
. 154
1.62
May .
. 134
5.60
June .
. 135
13.89
July . . V '
. 132
9.47
August
. 14.3
4.26
September .
. 131
October
. 156
November .
. 171
5.85
December .
. 168
.74
Annual
. 153
48.03
In July of last year (1876) I reported for duty at Camp Douglas. Salt
Lake City, Utah, but saw no febrile cases until quite recently. Two com-
panies of the Fourteenth U. S. Infantry, which had been out with General
Crook against the hostile Sioux from November, 1876, until the following
January, arrived at the post to take station immediately after the campaign
was finished. A day or two after their arrival, the men began to report
at surgeon's call in a condition similar to that with which I had become
familiar at Fort Bridger. A dozen were furnished with a cathartic, and
quinia in five grain doses thrice daily, but were not taken on sick report.
Five men and one officer, however, had become so oppressed with the
mountain fever poison that they had to be reported sick and retained
under treatment from three to nineteen days. And it is interesting to
remark, as being the only case out of many, that one man, after having been
discharged from hospital as entirely recovered, made his appearance in
eight days with a recurrence of the febrile attack;3 but it was readily
removed by quinia, and no subsequent relapse has taken place. These
men had suffered much from exposure while on their campaign — during
the latter part of it especially. At and after Christmas, as I am told, the
thermometer was more often below zero than above it.
Such has been my experience of the only peculiar febrile condition which
I have observed in a four years' service in the Rocky Mountain country,
showing itself in : —
1 Daniel Drake. The Principal Diseases of the Interior Valley of X. America.
Phila. 1854.
2 I have since met with tsvo similar cases of recurrence. Oct. 20, 1877.
1878.1 Smart, Mountain Fever and Malarious TTaters. 25
\
1st. A primary stage of one, two, or more weeks, during which the
individual is more or less oppressed by the influence of the materies morbi.
2d. The development of fever, more or less marked, and more or less
rapid in its course, with irregular remissions and much more mental de-
pression and muscular prostration than the patient's pulse and temperature
would prepare the observer to find.
3d. A typhoid stage marked by prostration, emaciation, low delirium
and coma-vigil.
It is to be observed that I have seen but few cases in the typhoid stage,
and few showing the transition to it from the remittent condition, but,
nevertheless, I do not hesitate in my opinion that these three conditions
are produced by the action of one and the same morbid influence, and
that they constitute the infancy, adolescence, and maturity of the mountain
fever of the pioneers. And in this opinion I have most important support
— for a summary of the above description of mountain fever read before
the Salt Lake City Medical Society, March 12, 1877, received the sanc-
tion of that body.
Xow, the question comes, Is this a fever sui generis, or are we to give it
recognition as typhoid, typlio-malarial, or malarial remittent fever?
And first as to typhoid. As already seen, the preponderance of the pub-
lished testimony is not in favour of this theory. Yet, beside the generic
traits of fever certain points of similarity exist between this disease and
enteric fever; for instance, the languor, depression of spirits, and intellec-
tual oppression, the remissions and exacerbations, the typhoid tongue, pros-
tration, and delirium. But closer investigation shows many and marked
differences. It runs no definite course ; for in one case the patient may
have been out of sorts for weeks before the febrile action is developed, while
in another the first stage may comprise only a few days. In one the fever
may go on from day to day (in the absence of proper treatment) without
much apparent change for the worse, while in another a day or two may
suffice to manifest the desiccation and darkening of the tongue. This same
irregularity applies to the history of the individual case as regards the
occurrence of the remissions and exacerbations. The temperature does
not run so high as in typhoid. jNo eruption is presented, no meteorism, no
iliac tenderness ; and if diarrhoea be present, as it usually is, it is dysen-
teric in character. Again, easily recognizable cases of typhoid fever are
rare in the Rocky Mountains, especially in the remote settlements, while
mountain fever is so common, especially in those same settlements, as to
be a name in the mouth of the people. At Fort Bridger, for instance, out
of a mean strength of 153 men, there were recorded during the eight years,
1866-73, 59 cases of mountain fever expressed as malarial remittent, and
but one of enteric fever. Lastly, quinia has no power to check the onward
course of typhoid, while its influence over this fever, particularly in its
first and second stage, is most marked.
As to the typho-malarial suggestions, if that fever be viewed as a com-
26
Smart, Mountain Fever and Malarious Waters.
[Jan.
posite, typhoid occurring in a constitution broken down by exposure to
malaria, it is excluded by the exclusion of typhoid. If, on the other hand,
it be considered as a peculiar manifestation of malarial poisoning, the sug-
gestion remaks to be discussed along with the malarial remittent theory
of mountain fever.
Fever from malarial poisoning is so many-faced in its appearance that
it cannot be excluded so readily as the typhoid by simple observation of
the symptoms. In fact, at first sight one is struck by resemblances rather
than by differences, as witness the similarity of the first stage to the dumb
ague of malarious districts, the remissions of the second stage, and the in-
fluence of quinia.
With regard to the effect of quinia, there appears to be a tendency in
the profession to bring in malaria guilty if this remedy testifies against it,
although the specification may be unsustained by any other witness. It is
poor logic when put down in black and white : —
Quinia is a specific in malarial disease.
Quinia is a specific in x.
x is therefore a malarial disease.
But it is a very good working rule, expressing as it does the greater
likelihood that the source of the malarial poison has escaped our observa-
tion, than that quinia, in view of our long experience of it, should be a
specific in other genera of disease. Dr. Patzki, of Fort Steele, illustrates
this tendency by saying, as quoted above: " The efficacy of large doses of
quinia proves its malarial origin," while he immediately continues r1 —
" That persons afflicted with ague rapidly recover in this climate was illustrated
in June and July, 18G7, when the troops brought from the swamps of Florida had
their systems tainted with this disease. During the two months 96 were rendered
unfit for duty out of a mean strength of about 200 men, and many more suffered
to a less degree. During the next four months but 17 cases occurred, and none
during the winter."
On page 319 of the Report on Hygiene I find myself reporting from
Fort Bridget* that : —
' ' The intermittents are imported diseases. During my service at this station,
I have found no case which originated in the locality. On the contrary, the ten-
dency in the imported cases is to longer intervals and ultimate recovery. Every
monthly report which shows an unusual number of cases of this disease shows at
the same time some change in the garrison. During succeedings months the
number becomes smaller, until a new company or a detachment of recruits brings
a fresh influx of intermittent cases. In one notable instance, occurring in June,
1869, when the garrison was relieved by troops from Florida, 40 intermittents
were taken on sick report in a strength of 199 men, or 200 per thousand for the
month, while the average for the year (computed from the eight years, 1866-73)
is only 1G7 per thousand."
The post surgeon of Fort Shaw, Montana, reports on page 434: " I
have known of no cases of intermittent fever that have with certainty
originated in the country."
Again, if note be taken of the exposures of the two companies of the
1 Report on the Hygiene of the IT. S. Army, page 385.
1878.] . Smart, Mountain Fever and Malarious Waters. 27
Fourteenth Infantry, which furnished me with my recent cases, it will be
found that they received the mountain fever poison while the temperature
was at times below zero, and always below the freezing point— a fact which
certainly does not fall in with our established notions of malarial poisoning.
If then mountain fever is a malarial remittent, as the general testimony
seems to determine it, the question arises — How can we have a malarial
fever in a region of country where there are seemingly no malarious traits,
and where it is noted that sufferers from malarial poisoning rapidly throw
off the thrall of the disease?
Do we have other telluric influences — other than the marsh malaria — a
mountain miasm for instance, similar to, but differing in its habits from
the swamp poison, and producing a disease generically similar to but spe-
cifically distinct from our malarial fevers?
Or, can we have malaria, exhaled from the lowland swamps, transported,
to Fort Bridger for instance, across vast tracts of interlying country, and
this in the face of the steady northwest wind which blows over the poet
from the higher regions of the mountain range, the said malaria being so
modified in its transit as to produce the mountain remittent with its pecu-
liarity of symptoms at seasons which are not the seasons of visitation in
recognized malarious districts?
In this connection I desire to refer to certain experiments which seem
to throw light on the causation of this fever.
While stationed at Fort Bridger I spent several months in examining
the various spring, well, and river waters made use of by the troops in
Nebraska, Wyoming, and Utah. The most remarkable point developed by
these analyses was the large amount of un decomposed organic matter of
vegetable origin which was contained by all the river waters, even those
which were looked upon as pure mountain streams. That the organic
matter was vegetable in character was inferred from the absence of the
sodium chloride which is the invariable accompaniment of animal matter;
that it was recent, or at least in good preservation, by the absence of the
nitrites which would have resulted from its decomposition.
For the determination of this organic matter Wanklyn and Chapman's
process was adopted, as affording more delicate results than the coarse
method by ignition, and more trustworthy than the permanganate decolor-
ations. This process depends on the transformation of the nitrogen of
the organic matter into ammonia by distillation with permanganate and
caustic potash, and the estimation of the resulting ammonia by Xessler's
solution. The facts developed have such an important bearing on the
question of water-supply that I shall detail the steps of the process, that
I may guarantee the results to those who have a practical knowledge of
its manipulations.
500 cubic centimetres of the given water were distilled from a large
retort, connected with a Liebig's condenser, until 50 c. c. had collected in
the receiver. This distillate contained most of the free ammonia of the
28
Smart, Mountain Fever and Malarious Waters.
[Jan.
water. It was estimated by means of Nessler's solution. 50 c. c. more
were then distilled and the ammonia determined as before. If the second
measure of 50 c. c. showed the presence of ammonia a third was distilled,
and, if necessary, a fourth, until proof was obtained of its complete removal
from the water remaining in the retort. Ten grammes of caustic potash
and .400 grm. of permanganate were then dropped into the retort — either
dry or in solution in distilled water which had been proved to yield no
ammonia when distilled with these chemicals — the distillation continued,
and the ammonia evolved in the destruction of the organic matter esti-
mated in successive measures of 50 c. c. of the distillate, until no more was
found to be given off.
In these determinations the greatest care was taken in conducting the
distillation, in watching the coloration produced by the Nessler's solution,
and in proving the strength of the standard ammonia solution.
Now, to appreciate the results which were obtained it must be premised
that the authorities in sanitary science, who have had most experience of
this method of organic determination in water analysis, lay it down as a
rule that water containing .10 part per million of ammonia from nitro-
genous matter should be regarded with suspicion, while that which contains
.15 ought to be condemned as dangerous to health.
The purest of the river waters examined were those of Lodge-Pole
Creek at Sidney Barracks, Nebraska, Black's Fork at Fort Bridger, Wy-
oming, and the Douglas Brook at Camp Douglas, Utah — and these gave
respectively .19, .20 and .28 part per million of ammonia from the nitro-
gen of dissolved organic matter.
This was so singular and so unexpected that I proceeded to investigate
the matter more closely. At first I inclined to the opinion that the water
must collect this large quantity of organic contamination in its course along
the valleys. I thought of the immense amount of decaying vegetation in
this wild region where no crops are harvested, but wdiere the growth of to-
day uprises from the decay of ages. I gave all credit to the effect of bea-
ver dams in stagnating the waters above them, which afterward found their
way slowly into the main current and polluted it with the organic debris
which they had dissolved during their stagnation. But this theory was
scarcely tenable in the face of the fact that streams running in a rocky bed
and with but little vegetation near their radicles were found to be nearly
as much impregnated as those which had a slower course in the tangled
brush-wood of lower-lying valleys. However, I could form no better theory,
and as a step in the direction of testing it, I set to work in the first place
to prove the purity of the water which fed these streams.
The springs I had already on my record as pure — Camp Douglas Spring,
for instance, containing but .10 part per million; there remained there-
fore as feeders the rain-fall and the melting of the snow.
The first heavy snow-fall of 1875 occurred about this time; I collected
it carefully in clean vessels, melted the samples, and on examination was
1878.]
Smart, Mountain Fever and Malarious Waters.
29
surprised to find that it contained nearly twice as much organic matter as
the average of the river-waters examined. A second" fall two days later
gave a like result. The subsequent snow storms of that season yielded less
of organic impregnation, although i irj all cases it was in excess of that con-
tained by the waters of the running streams.
At this time I did not connect the vegetable impurity in the snow-water
with any practical question, except in so far as to conclude that the organic
matter with which we had to do in our western streams must differ in
quality from that which British health officers found in their water analy-
ses, and that instead of being guided by their rules in forming our opinion
as to the wholesomeness of a water we must form rules based upon our own
experience. And as Black's Fork, Douglas Brook, and Lodge-pole Creek
were looked upon as pure mountain streams, although their waters contained
up to .28 part per million ; and again, as I was informed by the medical
officer on duty at Fort Sanders, the water supply of which contained .50
part, that certain low fevers which had prevailed in the neighbourhood
were vaguely rumored as being connected with impurity in the water —
I felt warranted in summarizing that with us water containing less than .30
might be viewed as wholesome, from .30 to .40 suspicious, and from .40
to .50 dangerous.
I was satisfied with having detected the origin of the organic taint in
our so-called pure streams : that it consisted of vegetable emanations and
debris swept up by the winds from the face of the continent and pre-
cipitated by cold and moisture along with the snow from the higher regions
of the atmosphere.
But, that it was productive of injurious effects on the human system,
except when existing in unusual and excessive proportion, and that I had
seen and treated these injurious effects and speculated on their hidden
cause, did not occur to me until the following spring, when I found myself
again face to face with the mountain remittent, and saw the stream of Black's
Fork, which furnished the water supply of the post, swollen to thrice its
usual volume by the melting snows, and charged, as I supposed must be
the case, with the larger amount of organic matter — which the predomi-
nance of snow-water gave to the stream. Then it was that I referred to
my laboratory note-book for various determinations of the organic matter
in Black's Fork, which I had made while puzzled as to whence the con-
tamination was derived ; and there I found recorded —
Black's Fork water June 14, 1875, .28 part.
" " July 19, " .24 "
" " Aug. 28, " .20 "
" " Oct. 12, " .16 "
Another recorded experiment is interesting as showing the organic con-
tamination of this stream when at its purest. It was performed simply to
ascertain the organic impurity in the ice-supply of the post, but as this ice
SO Smart, Mountain Fever and Malarious Waters. [Jan.
was the solidification of the water during the winter mouths when free from
all contamination by melting snows, the result was now viewed as expressly
the minimum impurity of Black's Fork.
Melted ice from ice-house, stored in February, 1875, issued for use and
examined August 14, 1875, contained .14 part per million.
The testimony of these figures in favor of a water origin of the fever,
showing a maximum and minimum of organic taint corresponding with a
maximum and minimum of visitation, Avas so direct that I felt chagrined
at having failed to recognize it sooner — that my search for the origin of
the impurity had so preoccupied me as to exclude from the mental field
that view of the results of the contamination which now seemed to have
lain so plainly exposed.
To complete the series two examinations in 187G may be given : —
Black's Fork water, April 21, 1876, .20 part.
" " " May 15, " .28 "
Rhetorically we make use of snow as a symbol of purity. Dr. Parkes,
however, informs us1 that "there lias long been an opinion that snow-water
is unwholesome, but this is based on no reliable observations." The above
experiments demonstrate cause sufficient to account for its unwholesome-
ness, and as to the reliability of the observations, I can only say that they
were carefully performed, and that the experience gained in conducting
over fifty distillations for organic matter in potable waters, superintended
their performance.
Besides the Fort Bridger experiments already referred to, and some half
dozen examinations which were not recorded, as giving at the time no new
light on the subject, but simply corroborating the accuracy of those first
made, I have conducted a series of examinations during the past autumn
and winter at Camp Douglas, Utah. They are given below : —
Free
Organic
Ammonia.
Ammonia.
1.
Snow ;
large, heavy iiakes, November 15, 1875 .
.30
.50
2.
Snow ;
large, heavy flakes, November 17, 1875 .
.30
.50
S.
Snow ;
large, heavy flakes. March 21, 1876
.10
.60
4.
Snow ;
small, granulated, October 30, 1876
.32
.20
5.
Snow ;
small, granulated, October 30, 1876
.32
.22
6.
Snow ;
flukes, December, 22, 1876 .
.02
.40
7.
Snow ;
flakes, January 29, 1877
.04
.46
8.
Snow ;
small flakes, Februarys, 1877
.18
.34
9.
Snow ;
large, heavy flakes, March 6, 1877
.30
.58
10.
Snow ;
fine, granulated, March 8, 1877
.30
.22
11.
Sleet ;
March 31, 1877
.28
.28
12.
Rain ;
October 17, 1876
.20
.16
13.
Rain ;
March 29, 1877
.28
.18
14.
Rain and sleet ; April 2, 187 7 .
.28
.22
1 Manual of Practical Hygiene. London, 1866, p. 9.
1878.] Smart, Mountain Fever and Malarious Waters.
31
These determinations of the organic matter in snow-water, when taken
in connection with determinations by the same process of organic matter
in the water of our running streams, amount almost to a demonstration
of the origin of the latter. It will be seen that the snow-water contains
from .20 to .60 part per million of ammonia from nitrogenous impurity,
but the average snow-fall of the year has an impurity approaching more to
the higher than the lower figure, since the great mass of the snow which
falls on this mountain country, and lies until melted by the warmth of the
succeeding spring and summer, contains from .50 to .60 part per million.
These are the heavy snow-falls, consisting of large, moist flakes which,
continuing for two or three days at a time, pile up so many feet of snow
all over the face of the country. The snows which are, comparatively
speaking, slightly impregnated with organic matter, are the light granula-
tions which fail in but insignificant showers, and the drifting storms of
small, dry crystals, which seldom add more than an inch or two to the
winter's covering. Estimating by experience the relation between the
heavy snow-falls, with their large proportion of organic matter, and the
lighter falls containing a smaller proportion, I feel confident that I am not
exceeding the truth in placing the average contamination of snow-water
at .45 part, per million.
Assuming this figure to be correct, and estimating the organic matter of
our streams when purest at .14, the occurrence in Black's Fork during the
months of April, May, June, July, and August of .20, .28, .28, .24, .20 seems
to be accounted for ; the conclusion arrived at being that the impurity of
our river water is derived from the atmosphere chiefly through the winter
snows. Rain-water is purer in this respect. The degree of cold, no
doubt, accounts in a measure for the greater precipitation of organic mat-
ter with the snow-flake, but the feathery structure of its crystals, present-
ing a larger surface for the condensation and entanglement of all floating
particles, makes the heavy snow-storm a more efficient purifier of the at-
mosphere than the rain shower, by sweeping to the earth more of the
vegetable debris which may have accumulated in the upper strata of the
air.
Of this vegetable debris what is so likely a constituent as the cause of
the malaria which emanates from such vast districts of country? Here the
question is begged, but under the circumstances is this too much to require ?
A non-malarious country is affected at a certain season with a malarious
disease ; this season corresponds with the contamination of the drinking-
water by vegetable matter brought from distant regions. Swamp malaria
is known to be transported by winds. It is known to rise mist-like and
be wafted mountainwards from the valleys in which it is exhaled. And if
more ponderable matter of vegetable origin be carried into the higher
strata of the atmosphere to be subsequently swept down by the snow-fall,
why may not malaria accompany ?
32
Smart, Mountain Fever and Malarious Waters.
[Jan.
Many experiments are recorded to prove the germ theory of disease —
that the air around us is charged with invisible molecules potent for evil,
and, to my mind, every operation performed after the antiseptic teachings
of Mr. Lister is a proof of the existence of such germs. Were these germs
continually accumulating without provision for their removal, wherein
would consist the value of ventilation ? But nature's processes preserve
the air we breathe in comparatively pure condition. The snow and rain-
fall clear the atmosphere of such contaminations* What becomes of the
exhaled malaria if it be not swept down in like manner ?
Surgeon John S. Billings, U. S. A., in a recent lecture before the medi-
cal profession of Baltimore, Md., informs us1 that —
" The second object in hospital management is the removal of all dust which
has settled or lodged, and that this shall be a real removal, and not a mere scatter-
ing of it from one place to allow it to settle elsewhere. If, for instance, dust is
removed with a damp cloth, this damp clotli becomes a dangerous thing in itself.
If the external air be cold we may have a precipitation of moisture on the glass
of the windows, and in this moisture will be a considerable proportion of organic
matter, so much that if it be collected the fluid will give decided signs of putre-
faction. Now this precipitation of moisture and organic matter is temporarily a
purifying process."
Yes. And nature's grand precipitation of moisture and organic matter
in the form of our winter snow-falls, is also a purifying process, enabling
ourselves, in our small way, to purify the atmosphere of our wards by
admitting the air which she has purified to drive out and dilute that which
we have not as yet found means of purifying after her fashion by pre-
cipitation.
This on the supposition that malaria is an entity separate and distinct
from the organic matter which can be chemically recognized, but who shall
say that it is so, or that it resides in such and such impalpable particles of
the organic matter and not in others ? My own opinion is that malaria in
the upper regions of the air bears the same relation to the organic matter
existing there, and correspondingly when both are precipitated into our
water supply, that organic matter in the wards of a hospital bears to the
carbonic acid accumulated with it. Carbonic acid, when in large excess,
is pernicious from its own peculiar properties, so, no doubt, with the vege-
table impurity of the water; but- under the ordinary circumstances of our
present ventilation system, carbonic acid is insignificant in itself, and
becomes of consideration only as a measurer of the otherwise immeasura-
ble organic matter of our wards. If we have a ward or sleeping room
which gives a large proportion of carbonic acid, we infer a correspondingly
large proportion of deleterious animal exhalations, and ventilate accord-
ingly. So it may be conceived that a large proportion of vegetable snow-
derived organic matter in our potable waters is of consideration mainly as
a measurer of the otherwise unmeasurable malaria which it contains.
1 On the Plans for the Johns Hopkins Hospital at Baltimore. New York Medical
Eecord, March 3, 1877.
1878.] Smart, Mountain Fever and Malarious Waters. 33
This malaria, evolved from the swamps and jungles during the heats of
summer and early autumn, is swept off by winds, and would accumulate
to a pest cloud enveloping the earth but for the autumnal rains and winter
snows which bear it back to the surface of the soil, and bury it ultimately
in the ocean ; the rivers thus becoming Nature's drains to carry off the
sewage of the atmosphere.
Autumnal rains are here mentioned as purifiers, for, although rain-water
is purer in respect of recognizable organic matter than that derived from
the snow, it by no means follows that it is less charged with disease germs
— less charged with malaria from the atmosphere. The test for the pres-
ence of malaria in the rain showers falling upon our mountains must be the
coexistence of a rain-caused rise in the streams, with an increase of such
cases as we have already referred to malaria in the snow. The cases which
occur at Fort Bridger in November (see above) show the morbific agent
which causes the remittent to have been at work ; and it is just at this time
that the stream is carrying off the autumn rains which fall upon the moun-
tains. Toward the end of September rain storms begin, and although the
fall at Fort Bridger is small, it must be remembered that it is not the fall
at the post, but the much greater fall along the mountain ridge which has
to be considered.
We may not suppose that all snow is thus charged with malaria and
other deleterious matter of vegetable origin. The evaporation from the
ocean precipitated as snow upon some island or sea coast surface may be
perfectly pure so far as organic impregnation is concerned. The snow
which falls on the Polar Seas is presumably free from disease germs.
Whaling vessels cruising in these seas are in the habit of renewing their
supply of fresh water about the beginning of July from fresh water ponds
or lakelets, formed on the ice floes by the melting of the snows of the pre-
vious winter under the steady rays of the long summer sun. This water
is used as fresh water for all purposes on board until the return home, two
or three months later; and no suspicion has ever attached to it. Large
fleets sail from North Britain yearly on these whaling expeditions, and as
the vessels are strongly manned — fifty to eighty of a crew — the case seems
clear in favour of the purity of this water. But, however this may be,
certain it is that the snow-fall on the backbone of the American Continent
is impregnated with deleterious vegetable matters.
In discussing questions of malarial poisoning the profession generally
holds in view a pernicious exhalation pervading the air, and affecting the
system through cutaneous and pulmonary absorption. Yet by many
authorities the possible entry of the poison through the medium of drink-
ing water is adverted to. Thus, Professor Maclean informs1 us that : "It
is a common belief in India that water is capable of absorbing malaria,
1 Reynold's System of Medicine, vol. i. p. 59.
No. CXLIX Jan. 1878. 3
34 Smart, Mountain Fever and Malarious Waters. [Jan.
and that periodic fevers, dysentery, and even cholera, are produced by
drinking water so charged." Dr. E. A. Parkes refers to the point at
greater length. "In modern times," he says,' "the opinion of Lancisi,
that the air of marshes is the sole cause of intermittents, has been so gene-
rally adopted, that the possibility of the introduction of the cause by means
of water as well as air was overlooked. Still it has been a very general
belief among the inhabitants of marshy countries, that the water could pro-
duce fever." And he then quotes several instancet in which paludal fevers
were attributed to malarious waters.
Now, although, according to such teachers as make reference to the
topic, rapidity of development and fatality of issue are acknowledged cha-
racteristics of malarial disease when introduced by water, it must not be
forgotten that these impressions are derived from experiences in " notori-
ously unhealthy" districts, where the water, we may suppose from its mala-
rious surroundings, is strongly charged with the poison. What might be
the effect of the continued ingestion of a weakly tainted water does not
appear unless the cases above described as mountain fever are allowed to
be malarial disease from water impregnation.
Exposure to aeriform malaria produces effects proportioned to the dilu-
tion or concentration of the toxic principle. Hence we may expect analo-
gous results from the watery solution. Diluted exhalations yield us dumb
agues and mild intermittents, while the concentrated poison of the Indian
jungle prostrates the system with a malignant remittent. So the weak
solution may be credited with the disordered condition which has been in-
dicated as the first stage of mountain fever; a continuance of ingestion, or
an increase of poisonous qualities may develop the other stages ; while the
strongly charged water of an unhealthy district may at once strike the
patient down with a pernicious fever.
In view, then, of the above-recorded experiments on snow and river
water, and of the ideas connected therewith, may we not feel warranted
in claiming that mountain fever is not dependent upon any peculiar
mountain miasm, but is a malarial remittent with adynamic tendencies —
and that some plausibility attaches to the theory of its origin in malaria
introduced into the water supply by the winter snow-falls? This theory
explains such differences in the natural history of the mountain fe ver poison
as would lead one, at first sight, to imagine a peculiar influence with cha-
racters specifically distinct from those of malaria ; the latter lying low in
swampy valleys, amid a luxuriant vegetation, most pernicious in hot cli-
mates, and in seasons of the year which correspond with the drying up of
the annual floods, and producing in the diluted exhalations of more tempe-
rate climes a form of fever intermittent in tendencies ; the former prevail-
ing in upland regions, amid a meagre vegetation, and in a climate which
from altitude assimilates to the Arctic — its prevalence corresponding not
Manual of Practical Hygiene, p. 55.
1878.] Smart, Mountain Fever and Malarious Waters.
3,3
with the drying up of the floods, but with their rise and progress, and pro-
ducing in the system a remittent instead of the intermittent febrile form.
This theory is based upon the following considerations : —
1st. The malarial character of the disease as testified to by the majority
of observers, by the influence of quinia, and by the differences in history,
symptoms, and habitat between it and enteric fever.
2d. The absence of indigenous malaria in the mountain country, as shown
by the reports of certain medical officers who have adverted to this point ;
although the presence of intermittents would be no argument against the
theory, but would rather point to the existence of local sources of exhala-
tion.
3d. The presence of vegetable organic matter, and the probable presence
of malaria in all the rain and snow showers, but especially in the heavy
lar^e-flaked falls which constitute the mass of the winter's snow. The
probable presence of malaria in the snow appears to be a weak link in the
chain of argument, but it must not be forgotten in estimating its weakness
that the probable presence is all that can be allowed in marsh air, the actual
presence being insusceptible of demonstration.
4th. The presence of the same vegetable contamination in the water of
the running streams as proved by experiment.
5th. The correspondence in time between the melting of the snow and
the endemic occurrence of the mountain remittent — May, June, and July
being, as already stated, the months of visitation at Fort Bridger. Now
as this post is 7000 feet above the sea level, and, moreover, situated on the
northern slope of the mountains, its springs are late. The thaw does not
begin until toward the end of April, and the waters of the creek continue
turbid and laden with the organic impregnation of the snow until July.
Trout fishing, in fact, begins about the middle of that month, and no sport
of this character can be entered upon until the waters have fallen and be-
come perfectly free from turbidity.
6th. The correspondence in time between the autumnal rain-caused rise
in the stream, and the increased prevalence of the fever as shown by the
Fort Bridger record for November.
7th. The correspondence in time between the freedom of the face of the
country from snow — a few white patches only being visible on the highest
peaks of the range — and the exemption of the post from febrile attacks-
For the records show no case of mountain fever during the months of
September and October, and these are the months when the stream is at
its lowest and purest, so far as it is a question of organic contamination.
8th. The sporadic appearance of mountain fever during seasons when
the evolution of malaria from mountain marshes and river valleys is ren-
dered unlikely by the low temperature, as in the cases of hunters, miners,
and cattle herders, and, on a larger scale, in the cases above mentioned as
having occurred in the Fourteenth Infantry — corresponding with snow-
36
Smart, Mountain Fever and Malarious Waters.
[Jan.
water drinking in every case investigated. The Fourteenth Infantry dur-
ing the early portion of their campaign were several times obliged to camp
near bad water — melted snow collected in natural tanks — and during the
latter part the water supply for all culinary and camp uses had frequently
to be derived from the snow covering of the earth. Here the increased
prevalence of mountain fever at Fort Bridger during the month of January
may be referred to, and attributed to accidental circumstances of a charac-
ter similar to that which gave Camp Douglas a series of cases in January,
1877.
9th. The fact that mountain fever is not so prevalent now, nor so fatal
as in the so-called " early days," corresponding with .improvement in the
mode of trans-continental travel to the settlements, and improved water
supply at them. One cause of the lessened fatality is, of course, to be
found in the extended recognition of the power of quinia over the progress
of the disease, but the diminished prevalence must be referred to the water
supply. The emigrant is now whisked by rail in a few days from the
Atlantic coast to the Rocky Mountains, and we never find that his arrival
is signalized by prostration from the mountain fever.1 In earlier times,
however, when the trip implied months of weary marching, and a water
supply contaminated by melting snow, the disease was. as recorded at the
beginning of this paper, both common and deadly. So, in the settlements,
well-digging, by furnishing a purer supply than the running stream, the
beaver dam, or stagnant pond, has been followed by diminished prevalence.
In this connection I cannot refrain from quoting a suggestion by the late
Professor Parkes : — 2
"Is it not possible," he says, "that the great decline of agues in England is
partly due to a purer drinking water being now used ? Formerly, there can be
little doubt, when there was no organized supply, and much fewer wells existed,
the people must have taken their supply from surface collections and ditches, as
they do now, or did till lately, at Shcerness."
10th. The appearance of the fever in all its original characters among
hunters, miners, prospectors, surveyors, herders, soldiers, or scouting expe-
ditions, and all parties who are thrown for their water-supply on the streams,
ponds, pools, dams, and natural tanks which were the sources of supply in
the days of the pioneer emigrants.
11th. The appearance of the disease modified by medical supervision at
such posts as Fort Bridger, where the water supply is drawn from the run-
ning stream.
12th. The rarity of its appearance at such posts as Camp Douglas, where
the water is kept comparatively free from malarial contamination. At this
post —
" The water is taken from Red Butte Creek, a stream that flows through the
reservation from Red Butte Canon, which is a cut in the mountains, situated to
1 Dr. Benedict, Salt Lake City.
2 Manual of Practical Hygiene. Note on p. 56.
1878.] Smart, Mountain Fever and Malarious Waters. 37
the east of the post. About one-third of a mile up the stream the water is turned
from its natural channel by a dam 100 feet long and 6 feet high, substantially
constructed of stone, timber, and earth, and provided with waste- way and over-
flow. From the raised pond formed by the dam an open acequia, about 850 feet
long, conveys the water to a reservoir of the capacity of 700,000 gallons, which
is located on a natural slope above the p%ost and a thousand feet distant from the
line of officers' quarters. The reservoir is formed by excavating the side of the
foot-hill of the mountains, and the earth removed therefrom, being placed along
the lower side and ends, makes a firm embankment 30 feet wide at the bottom, 6
feet wide at the top, and Sj feet high. The depth of the water in the basin will
average 6i feet. A waste-way and flush-gate constructed of wood are provided,
so that the contents of the basin can be run out in a few minutes when desired.
The level of the water in the basin is high enough to give a head of 90 feet at the
officers' quarters."
This water is distributed by five inch mains, four inch laterals, and
three-quarter inch service pipes.
"During the months of February, March, and April the water in the creek is
usually very muddy. When that is the case it is desirable that very little water
be allowed to run into the reservoir, as the sediment that will accumulate from a
large stream will very soon fill the basin. When there is danger of the supply in
the reservoir falling short, and water must be let in, it will be well for the man in
charge to observe the character of the water, and select days for refilling when
the stream is less turbid than usual. In the early morning the water will be found
more free from earthy impurities than in the afternoon."
The quotations are from the report of Captain Geo. W. Davis, Four-
teenth Infantry, who superintended the construction of the post. His
suggestions are born of a thorough knowledge of his subject. Yet, had
his object been the preservation of the water supply, not simply from sus-
pended matters, but from malarial contamination, he could not have laid
down better rules for the guidance of " the man in charge." The result of
this is that the reservoir water is always freer from organic impregnation
than that of the creek. A comparison, made March 26, 1877, when the
stream was by no means turbid, showed the running water to contain .22,
while the post supply gave only .16 part per million.
The freedom of the post from malarial remittents can thus be placed in
juxtaposition with an improved water supply ; it is to be regretted, how-
ever, that the health of the garrison anterior to the construction of the
reservoir cannot be brought into the question under discussion. Surgeon
E. P. Yollum, IT. S. A., reports, as above quoted, that the last epidemic
of mountain fever occurred in 1871-72. His official records for those
years show many quotidian and tertian intermittents, which may, how-
ever, have been imported, and 16 cases of typhoid fever, 6 of which proved
fatal, but no cases of remittent fever. The typhoid cases may, therefore,
be regarded as examples of the mountain fever which begins "as an inter-
mittent, passing on to a remittent, then into a typhoid condition." He
records also a large amount of sickness, " chiefly of a febrile and catarrhal
character," among the families in garrison, but, as he attributed it, to rot-
ting wood, dampness, and want of ventilation and sunshine about the
foundations of the quarters, and as these quarters were abandoned in favour
88
Smart, Mountain Fever and Malarious Waters.
[Jan.
of substantial stone buildings at the time of the construction of the reser-
voir, the case must be set aside as too complicated for admission into this
argument.
Having thus identified mountain fever as a malarial remittent, and
referred it for causation and explanation of its peculiarities to the ingestion
of malarious water rather than to exposure to malarial exhalations, there
opens for our consideration a larger view than is seen on the slopes of the
Rocky Mountains. The necessity for a modification of our accepted theory
of malarial disease is apparent. Lancisi's doctrines are too exclusive.
Water must be recognized as claiming a higher place in the disease-pro-
ducing category ; and the importance of this recognition cannot be over-
estimated.
Leaving to my professional brethren in civil life the investigation of
malarial forms as caused solely by exhalation, that is, coincident with a
pure water supply, or as the result of malarious water with, or, if possible,
without the concurrence of aeriform malaria,1 the position shall be further
considered in this paper from a military point of view, as bearing on the
origin of the fevers which prevail in camps.
Surgeon J. J. Woodward, U. S. A., in his chapter on camp fevers,3
enumerates as the prevailing fevers of our army, typhoid, malarial remit-
tent, and typho-malarial, inversely in their order of frequency.
As the majority of the surgeons on duty with our army during the war
were drawn from practice in civil life, and were familiar alike with typhoid
fever and malarial remittents, it is presumable that enteric fever and remit-
tents from malarious exhalations were readily recognized ; but. according
to Dr. Woodward,3 in the fall and early winter of 1861, reports began to
come in to the Surgeon-General's office from various quarters that a new
form of fever was prevailing in our camps. Official attention was first
directed to the fact as occurring in the army of the Potomac. A board,
consisting of Surgeon A. N. McLaren, U. S. A., Surgeon G. H. Lyman.
U. S. Vols., and Assistant Surgeon M. J. Asch, U. S. A., was convened to
investigate this fever, and determine " whether it is to be considered an
intermittent or bilious remittent fever in its inception, assuming in its
course a typhoid tendency or a typhoid fever primarily" — the very point
at issue with regard to our Rocky Mountain fever. The result is interest-
1 When we find Dr. Jerome Cochran of Alabama, as quoted by Dr. Woodward in
his Remarks on Typho-malarial Fever before the International Medical Congress, 1876,
denying the existence of abdominal typhus in Mobile, and ascribing the various adyna-
mic fevers which there occur solely to malarial influence, there would seem to be
matter for investigation in the so-called "typhoid" fevers of malarious districts.
2 Camp Diseases of the U. S. Army, Phila. 1863.
3 Typho-malarial fever ; Is it a special type of fever ? Being remarks introductory to
the discussion of the question in the Section of Medicine. International Medical Con-
gress, Phila. 1876.
1878.]
Smart, Mountain Fever and Malarious Waters.
39
ing. The board investigated eases in many division hospitals and collected
a great deal of valuable information in writing by means of questions
addressed to the brigade and regimental medical officers of parts of the
army, which its members were unable conveniently to visit. The general
tenor of the replies confirmed the opinion formed by the members of the
board on the basis of their own personal observation. This opinion was
that, while a certain number of cases of ordinary typhoid fever existed in
the army, the large majority of the febrile cases were " bilious remittent
fevers, which, not having been controlled in the primary stage, have
assumed that adynamic type which is present in enteric fever."
Uninfluenced by this decision, Dr. Woodward, from whose interesting
pamphlet this account is abridged, formed the opinion that the prevailing
fevers of the army of the Potomac were hybrid forms, resulting from the
combined influence of malarial poisoning and of the causes of typhoid
fever. He believed that individual cases received their character in
accordance as the one or the other of these influences preponderated in
the individual. Full of these opinions he suggested as a designation for
the complex condition in question the name of " typho-malarial fever," and
succeeded in having this term added to the list of diseases printed on the
blank form for the monthly sick report. He has often regretted that he
did not also urge the preparation of a circular letter explaining why this
term had been adopted, and calling for special reports with regard to the
cases which it was intended to designate. As it was, however, he goes on
to say, u The term went upon the sick report, without any explanation, or
a word of comment. But, even under these circumstances, 23,346 cases
were reported as typho-malarial fever during the following year, showing
how widely the opinions I (he) had formed were shared by the medical
officers of the army."
It is indeed a matter of regret that Dr. Woodward failed to prepare a
circular explanatory of the term, as this neglect, as will be seen directly,
affords room for questioning his estimate of the result of its unexplained
appearance on the report.
Medical history shows clearly that the Hungarian fever was spotted ty-
phus modified by malarial complications. The propagation of pure typhus
in non-malarious districts by sufferers from the army fever leaves no room
for doubt on this point. And, if typhus with malaria gives the army
surgeon a hybrid to treat in countries where typhus prevails, it is ground
for admitting that typhoid may also furnish a hybrid where it is the preva-
lent fever. But to attribute all adynamic forms of fever occurring in
camps to the modified action of the materies morbi of typhus or typhoid
fever seems to be taking a step beyond the authorization of facts.
The Gottingen epidemic began as a remittent, and, after the fever was
fairly under way, presented many of the symptoms of ordinary typhoid ;
in its treatment extract of Peruvian bark often proved highly efficacious.
40 S mart, Mountain Fever and Malarious Waters. [Jan.
This, in brief, is the definition usually given in our Rocky Mountain fever.
But in the one as in the other there is no evidence of the presence of
enteric fever. It may bave been present in Gottingen, very probably it
was present, but: — "Dysenteric sloughs frequently existed in the colon.
Nowhere, however, do I find any description of the bulky tumefaction,
ulceration and sloughing of the glands of Peyer which is characteristic of
typhoid fever."1 The dysentery which existed in connection with this
Gottingen epidemic bears strongly on the relative causation of this fever
and that which I have described as mountain fever.
The Walcheren epidemic began also as a remittent, speedily, however,
running into a continued fever of typhoid type with muttering delirium,
small rapid pulse, dry black tongue, sordes-covered teeth, fetid odour, and
black discharges from the bowels. Here also, at the autopsies the charac-
teristics of dysentery were frequently found in the colon ; although occa-
sional lesions of the small intestines would seem to indicate in certain
cases the presence of the enteric fever poison.
In our own war we undoubtedly met with uncomplicated typhoid cases,
with typhoid poison in malarious subjects — Dr. Woodward's hybrid —
and with recognizable remittents; but were there no others? My own
experience leads me to affirm their existence; a period of broken health
during which the soldier laboured to throw off his bad feelings and stick
to duty, followed by a remittent fever becoming adynamic in its course,
with dysentery tending to hasten a fatal issue.
I was on duty in the field to the end of the war, and saw many such
cases in their inception, few comparatively at their termination, as field
division hospitals were usually kept in light marching condition. Dej 6t
hospitals in the rear afforded better opportunities for studying the conva-
lescence and autopsical appearances. Yet, there Avere times, as during
winter quarters, when field hospitals Avere permitted to retain and treat
such sick of their commands as were within the limit of their capacity.
Thus an occasional autopsy would take place, shoAving such strongly marked
dysenteric lesions as to give my mind a tendency to accept the theory of
the malarial origin of the case under examination rather than that of its
typhoid genesis.
But, in a question of such vast extent as the nature of camp fever, the
experience of one becomes swamped in that of the many.
The experience of the many during our late Avar, as referred to in Dr.
WoodAvard's Araluable paper, is comprised in the report of the Board to the
effect that the fever Avas essentially a malarial remittent, and in the popula-
rity of the name " typho-malarial" which Dr. Woodward regards as an en-
dorsement of his own vieAvs. With regard to the former I ha\*e nothing
to say, but the latter requires a Avord of criticism.
1 Dr. Woodward, op. cit.
1878.] Smart, Mountain Fever and Malarious Waters.
41
It must be remembered that the word typhoid has become a hack in
medical literature, expressing on the one hand the special fever of that
name, otherwise known as abdominal typhus or enteric fever, and on the
other any low or adynamic condition of system occurring in the progress
of a disease unconnected with the poison or germs which produce enteric
fever. Under ordinary circumstances the meaning of the word can be
arrived at from the context, but when we come to the formation of com-
pound words into which the ambiguous typhoid enters, its signification
may not be so clear. What is its value in typho-malarial ? Dr. Wood-
ward has no doubt on the point, because he knows the mental value he
stamped on the word when coined; but others are at liberty to give it a
different valuation ; and in fact its originator seems to acknowledge this in
regretting that he did not have a circular issued explaining why the term
had been adopted.
I am not prepared to say what amount of endorsement Dr. Woodward
can draw from the popularity of the term, but this I know that in my ser-
vice as medical inspector of the Second Army Corps, I have often stood
by the bed of a fever case and spoken of it to the surgeon in charge as
typho-malarial fever when the symptoms pointed to a low form of malarial
remittent ; while when enteric poison was manifest, either in the history
of the case, or by the presence of the eruption, typhoid stools or iliac ten-
derness, all ambiguity was thrown aside and the patient spoken of as af-
fected with typhoid. Malarial complication might be present, but it was
recognized as a complication, the typhoid element being considered as the
disease par excellence, the disease which caused, death ; just as after a battle
a gunshot wound of the chest would be regarded as the primum mobile of
death, although the injured man might be suffering from the effects of ma-
larial poison, and those effects might have contributed in no small degree
to the fatal issue by impairing the powers of the constitution.
Nor can it be supposed that I was the only medical officer who made use
of the term "typho-malarial" for the adynamic cases which did not present
one or other of the accredited symptoms of abdominal typhus. Had Dr.
Woodward, instead of the item " typho-malarial '," placed two terms on the
report, one " adynamic remittent" for the malarial cases, and the other
" enter o-miasmatic " as suggested by Dr. Geo. B. Wood, for the hybrid form,
it is doubtful if the army would have furnished as many cases of the latter
as it did of typho-malarial fever. In fact I can only see in the large num-
ber of cases thus reported the eagerness with which army medical officers
avoided a commitment to the theory of a typhoid fever in a malarious con-
stitution or a malarial fever assuming an adynamic type ; while at the
same time, on account of the ambiguity of the term, theorists on both sides
of the question recorded their cases as typho-malarial, and not those alone
who concurred with Dr. Woodward in his pathology of typho-malarial
disease.
42
Smart, Mountain Fever and Malarious Waters.
[Jan.
I am strong in my adherence to the opinion of the Board that the army
fevers were remittents " which not having been controlled in their primary
stage have assumed that adynamic type which is present in enteric fever," —
and my study of mountain fever has tended to confirm me in this belief.
Any one who has seen both diseases cannot but be struck by the resem-
blance between mountain fever and the camp fevers of our civil war.
Some medical officers indeed speak of the mountain remittent as typho-
malarial fever, the same term by which, no doubt, they recorded fever
cases among the troops from 1861 to 18G.>. Now, in the history of the
miners, prospectors, surveyors, old time emigrants and recent scouting ex-
peditions, antecedent to their prostration by mountain fever, what have we
in common with the troops who were the subjects of camp fever during
our great war? Exposures to climatic influences, over-fatigue, want of
sleep, anxieties, insufficient and badly cooked food, and impure water.
Again, what have we in common between the same troops and the garrison
of Fort Bridger previous to the appearance of its epidemic ? No expo-
sures, no fatigues, no want of food — nothing but the impure water. Of
course on account of the vast concourse of men collected in our war-
camps, typhoid fever prevailed and spread from case to case, complicated
in a majority of instances by the febrile action induced by exposure to
malarial exhalations and probably by the ingestion of malaria in tbeir
water supply. But in the mountain fever we have assuredly no specific
typhoid or enteric element ; we have simply a malarial remittent which if
uncontrolled in its earlier stages assumes the adynamic type which is pre-
sent in enteric fever.
If then in mountain fever we have an adynamic remittent uncomplicated
with the specific poison of typhoid fever, if also this mountain fever be
considered traced to its origin in the vegetable contamination of the drink-
ing water, and if we are at liberty to assume that a certain proportion of
our camp fevers were typho-malarial only in the sense of the superven-
tion of adynamia, it is pertinent to ask may not this certain proportion
of our camp fevers originate in a contamination of the water supply by
malaria, since impurity of water is the only circumstance common to the
previous history of the subjects of both fevers ?
Dr. Woodward, in insisting on the enteric element in all camp fevers,
divides them into two great classes, both comprehended under the title
typho-malarial.
1st. Those in which the malarial element predominates over the typhoid ;
and
2d. Those in which the typhoid element is most prominent.
But in view of what has been written above concerning the absence of
the enteric element or specific poison of abdominal typhus in the cases
which have been referred to the action of malarious waters, it is suggested
1878.] Smart, Mountain Fever and Malarious Waters.
43
that they are included in, and probably constitute the bulk of, Dr. Wood-
ward's first class. While as to his second, the typhoid (specific) element
being prominent, and the disease therefore easily recognized as a well-
known specific fever, although occurring in a system more or less poisoned
with malaria, there seems as little necessity for a special term to indicate
its existence thus complicated, as for the adoption of scarlatino-malarial,
or variolo-malarial, for an outbreak of scarlet fever, or varioloid among
the ague-smitten children of a malarious district. Or, granting the neces-
sity for a composite term, why include the other factor which so often
complicated these typhoid cases. If specific typhoid occurring in a mala-
rious system requires the adoption of typho-malarial, typho-malarial fever
in a scorbutic is equally entitled to recognition.
Our camp fever would, therefore be classified as follows : —
1st. Malarial fever ; the result of cutaneous and pulmonary absorption
of malarial exhalations.
2d. Aqua-malarial fever; the adynamic remittents caused by the inges-
tion of malarious waters.
3d. Typhoid fever ; originating in the specific causes of abdominal
typhus, and occurring either uncomplicated or complicated in
its symptoms and progress by exposure of the subject to mala-
rial exhalations, or deterioration of his constitution by the use oi
malarious waters.
This is simply a suggestion, but it is pregnant with important results in
army sanitation and in the preventive medicine of civil life. It may be
impossible to guard the system against malaria (aeriform) either in civil
settlements or among troops in the field. A pure water supply, however,
is certainly within reach of the former; while a recognition of the possi-
bility of a proportion of our camp fevers finding origin in malarious water
would be a step towards preventing their occurrence. The conditions of
field service, it must be admitted, imply many difficulties in the way of a
pure water supply. There is no time to search for it. That which lies
nearest to the camp must be used, and if it responds satisfactorily to the
rough tests of the senses, it is used without suspicion. But if we clearly
realize the dangers which may lurk in such water, we are forearmed. The
reactions of malarious water will be investigated, and the study will evolve
processes for the destruction of it s contained morbific agent ; so that, in
progress of time we may be able to say of the aqua-malarial section of our
camp fevers what we now say of our aqua-malarial mountain remittents : —
" They were once more common and more deadly than they are now."
Camp Douglas, Utah, April 9th, 1877.
44 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
Article II.
Tattooing as a means of Communicating Syphilis ; an Investigation
of Twenty-two Cases exposed to Inoculation with the Virus of
Mucous Patches, in Fifteen of which Syphilis followed. By F.
F. Maury, M.D., Lecturer on Venereal Diseases at the Jefferson Medical
College, Attending Surgeon to the Philadelphia Hospital; and C. W. Dulles,
M.D., late Interne at the Philadelphia Hospital.
In the beginning of September, 1877, a man presented himself in Dr.
Maury's wards in the Philadelphia Hospital, having upon his arm a sore
which had the characteristics of a chancre, and suffering from other evi-
dences of constitutional syphilis. The chancre was situated upon a tat-
tooed figure, which, had been placed there about two and a half months
before, by a "professional" tattooer who moistened his pigments in whole
or in part by inserting in his mouth the needles he used. So interesting
a matter at once engaged earnest attention, and led to the investigation,
first, of this one case, and afterwards of others in this city and in Reading,
where such extensive tattooing had been done that the physicians in the
town had had their attention attracted to its evil results, and were glad
to co-operate with us in determining their nature and extent.1
With regard to the latter point, however, we have not been able to ar-
rive at any, even approximate, conclusion. The number infected must be
much larger than that which we have been able to reach. For six months
has this tattooer had lesions, which are hereafter described, and during all
that time been doing his work whenever he had an opportunity, in Phila-
delphia, Reading, Jersey City, and New York ; and the majority of those
tattooed must have received the seeds of his disease.
From the time our investigations began, the securing and examining
the person of the tattooer was considered of the utmost importance, both
in the interests of science and for the safety of the community. Conse-
quently the police in different parts of the country were notified and search
instituted for him. On the 13th of October he was arrested, with all his
implements, in Philadelphia, and sent to the Philadelphia Hospital. He
was there fully identified by a number of his victims ; and later in the day
was, at the suggestion of Dr. Maury, committed to the House of Correc-
tion, where he is at present.
The following is his history, as given by himself and carefully compared
with the records of the Philadelphia Hospital and the statements of those
whom he tattooed.
1 At this point we wish to acknowledge with thanks our obligation to Doctors Mar-
shall, Kalbach, Kuhn, Reeser, Amnion, Luther, and Weidman, of Reading, for facili-
tating our investigations in the latter city ; and to Doctors Kerr and Anderson, internes
at the Philadelphia Hospital, for assistance in different ways.
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 45
James Kelly, set. 26, born in Bucks Co., Penna., by trade a painter,
but actually a vagrant; was examined October 13th, and again, through
the courtesy of Drs. Hendrie and Pennybaker, at the House of Correction
October 25th.
A man of extremely bad habits, a very hard drinker, a constant chewer
of tobacco, and of filthy personal appearance. He never had syphilis until
early in February, 1877, when he contracted four or five chancres, followed
by an inguinal bubo. Under self-treatment, he did so badly he was com-
pelled, Feb. 17th, to betake himself to the Philadelphia Hospital, where
he was treated locally by cauterization of the chancres with nitric acid,
and the application of lotio nigra and iodoform. On March 6th he left the
hospital and went to Reading, where he remained about a month, tattoo-
ing as occasion offered, then for a short time to Jersey City, and returned,
April 14th, to the hospital to be treated for mucous patches in his mouth
and condylomata about his anus. He remained here until May 16th,
when he left uncured, and going to Reading continued his tattooing.
From this time onward he seems to have communicated his disease to
most of the subjects of his art.1 Remaining in Reading nearly a month,
he then went for a few days to Jersey City, and on June 20th turned up
for the third time in the Philadelphia Hospital, with mucous patches and
condylomata still flourishing. On August 2d he was discharged for insub-
ordination, and went to Jersey City. About this time he had iritis. He
remained in Jersey City until October 6th, when he returned to Phila-
delphia, where he was one week later arrested and committed to the House
of Correction.
At the time of our examination he has slight inguinal adenitis, mucous
patches in his mouth, and a condylomatous patch at the bottom of his
scrotum. The mucous patches in his mouth are extensive. Two are
situated back of the angles and just within the lips. These are the only
present manifestation of syphilis.
The following was his customary method of tattooing : A figure having
been selected from a book of plates which he carried with him, he would
rub up India ink with water and pick the outlines in with a few needles
set in a holder. Then putting the needles in his mouth and sucking out
the residue of pigment, he would thrust them thus moistened into a bottle
of powdered vermilion and insert what adhered. To renew the vermilion
the needles were repeatedly wetted in his mouth. In some cases both
pigments were moistened with saliva, and in others he spit upon the
finished tattoo and rubbed it well with his hand or a dirty cloth he had.
The figures he made were often very handsome, and always skilfully
done. Indeed, this was his only means of livelihood, bringing him in
fees ranging from a drink of whiskey to two dollars, according to the ex-
tent and elaborateness of his work.
Such, then, being the history of the tattooer and his method of operat-
ing, we will proceed to the consideration of its results as exhibited in the
following twenty-two cases, which are not all that we have examined, but
such as we think of sufficient scientific interest, as well as of sufficient ac-
curary to report.
1 It will be noticed that all the cases here reported were tattooed at or after this
time, yiz : while he had mucous patches in his mouth.
4 6 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
It may not be amiss to state here that, to attain as much thoroughness
as possible, a definite plan of examination was first prepared and each in-
vestigation conducted according to it ; that every patient was examined
by us personally and scrutinized from head to foot ; that the asking of
leading questions was avoided, especially in regard to the primary lesions,
and that special inquiry was made to exclude the possibility of the syphilis,
where it occurred, having been acquired in some other way than by the
tattooing. Some apparent omissions in the accounts are attributable to
the difficulties encountered from ignorance, forgetfulness, or unwillingness
on the part of the patients.
We have arranged the histories in the following classes : —
I. Where the patients have never had syphilis, and yet were not inocu-
lated so far as is now known.
II. Where the patients had syphilis before being tattooed.
III. Where syphilis had never existed, but was communicated by the
tattooing.
Class I. Where the patients have never had syphilis, and yet were
not inoculated, so far as is now known.
Case I. — John M., set. 21, American, nurse examined first September
25, and repeatedly afterwards, in the Philadelphia Hospital, lie gives
an unexceptionable family history. Fifteen years ago lie had variola, of
which the scars are very plain. He had gonorrhoea four years ago, and
this year a stricture, which was successfully treated in the Philadelphia
Hospital, while at the same time he was circumcised for congenital phi-
mosis. He was tattooed by Kelly once in May and once in June. Two
figures were placed on each arm, the pigments, India ink and vermilion,
were mixed with Kelly's saliva. .Yet since that time, save a day's inflam-
mation of the arms, he has not had any ill effect. Careful and repeated
inquiry and examination fail to discover any trace of past or present
syphilis.
Case II John E., ret. 23, Am., iron moulder, examined in Reading,
October 1. He gives a good family and individual history. He was
tattooed by Kelly in June. The pigments used were India ink and ver-
milion. The former was mixed with water, but Kelly put the needles in
his mouth to suck off the India ink before putting in the vermilion.
After the operation was completed, the patient washed his arm carefully
with spring water. Since that time he has had no syphilitic manifesta-
tions that he knows of, nor does our examination discover any.
Case III Samuel F., a young man working in an iron foundry, ex-
amined in Reading October 1, gives a good family and personal history.
He was tattooed by Kelly in June. The manner was similar to that in
the other cases, in which though water was partly used to mix the pig-
ments, the needles were often put by Kelly into his mouth. Since that
time there has been no syphilitic manifestation whatever, so far as his
history or our examination can discover.
Case IV Joseph C.,a3t. 37, Am., labourer, examined in the Philadel-
phia Hospital October 10. Five years ago had a chancre appearing about
two weeks after exposure, and followed by a suppurating bubo in each
groin. These burst. Afterwards he had, so far as his memory serves
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 47
liim, no cutaneous eruption, nor any evidence of syphilis, except a year
later, an ulcer on his right temple and one on his leg. At the same time
he thinks he had swelling of the glands in the left axilla. He has never
had alopecia, nor iritis, nor any syphilitic development on a mucous mem-
brane. About the end of June he was tattooed by Kelly. Two small figures
were placed on the dorsum of his left forearm, and upon his chest a large
crucifixion. The pigments, India ink and vermilion, were mixed with
water, but Kelly put the needles in his mouth after inserting the India ink
so as to suck off what was left on them before putting in the vermilion.
The tattooing was followed by a very insignificant local inflammation,
and not a single evidence of syphilitic inoculation. At the time of our
examination, three and a half months after being tattooed, the man is in
perfect general condition. He has no adenitis, no alopecia, no eruption
whatever. We think there is no evidence that he has had syphilis at any
time.
This last case presents some difficulty in classification, but we place it
in this list because it appears to us that the lesion described as occurring
five years ago was not a true chancre. The account of the period of in-
cubation cannot be relied on after so great a lapse of time. The lesion
was followed by two suppurating buboes, which opened spontaneously, and
by no distinctive syphilitic manifestations whatever. The ulcers, appearing
a year later, we do not think can be fairly connected with the sore on his
penis.
If in this we are not mistaken, we have then four cases where, for
some reason, the subjects of the tattooing have entirely escaped syphilitic
inoculation. It is possible that even yet it may manifest itself, but up to
this time the immunity has been perfect.
Class II. Where the patients had syphilis before being tattooed.
Case V William W., aet. 23, Am., laborer, was examined in the
Philadelphia Hospital Sept. 22, and repeatedly afterwards. He gives a
good family history ; has been himself a steady but moderate drinker. In
October, 1876, he had gonorrhoea, and in February, 1877, a phagedenic
chancre, which destroyed his whole glans penis. This was followed by a
papular eruption on his legs and mucous patches in his mouth, one of
which was very large. While in the Philadelphia Hospital, and when these
secondary manifestations were at their height, he was tattooed by Kelly.
A figure of a bracelet was placed round each wrist. The pigments, India
ink, coal dust and vermilion, were mixed with Kelly's saliva. There fol-
lowed only a very trifling local inflammation, and no other effect that he
knows of. At the time of our examination he has papules and squamae
in his scalp, an unhealed ulcer of the stump of his penis, and a serpiginous
ulcer of the fibular side of his left leg.
Case VI — Thomas L., aet. 27, Irish, labourer; a man stubborn, igno-
rant, and mendacious, was examined, by courtesy of Drs. Morton and
Kirkbride, at the Pennsylvania Hospital September 25, and once later.
He gives a good family history. He denies any previous venereal dis-
ease, until our physical examination detects a fine parchment-like indura-
tion on his glans penis, when he admits he has had a chancre there in
May, but still denies any cutaneous manifestation.
48 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
About the end of June he was tattooed by Kelly. The figure of a cru-
cifix was placed on the ventral aspect of his right forearm. The pigment
used was coal dust, which was spit upon by Kelly and picked in with
needles. There followed moderate swelling of the arm, but no axillary
bubo. In about a month there appeared, on a spot of the figure repre-
senting the left nipple, a papule, which did not itch. This he scratched
with a pin, and it became a pustule, which spread until it formed an indurated
and elevated ulcer, having a diameter of about three-quarters of an inch.
This was poulticed, and an " Indian salve" applied ; some time afterward
he entered the Pennsylvania Hospital, where he was treated locally with
lotio nigra and constitutionally with red iodide of mercury and iodide of
potassium.
At the time of our examination he has on his body a few old maculae.
There are papules in his scalp, on his forehead, body — particularly where
his waistband has pressed — legs, and soles. He has a few crusted pustules
on his body. In his mouth is a mucous patch. The ulcer on his arm is
healing nicely. On his glans penis is the indurated scar of his old chancre.
He has enlargement of his post-cervical and right supra-trochlear glands, as
well as those in both groins and over both saphenous openings.
This case we cannot place in any other class than this because of the
peculiar scar upon his penis, which seems to be that of a chancre antedat-
ing his tattooing, and which we take to be the starting point of his syphilis.
Case VII. — David M., ret. 2G, Am., coach painter, was examined in
the Philadelphia Hospital Sept. 22, and repeatedly afterward. He gives
a good family and personal history. Previous to this year he never had any-
venereal complaint, though for ten years he has led an irregular life. About
the end of last April he contracted three sores upon his penis, which were
treated with iodoform, and healed in six days.
On the sixth of May, while in the Philadelphia Hospital, and, he thinks,
well, he was tattooed by Kelly. The operation consisted simply in putting
in three radii of an incomplete eight-rayed star, two and a half inches in
diameter, situated in the skin over the head of the right humerus. The
pigment used was India ink, which was mixed with Kelly's saliva. Fol-
lowing this, there was considerable swelling of his arm, which passed off
in a few days without treatment. In about two weeks, however, there
were developed three papules, one on each of the newly made radii, which
did not itch, but passed on to pustulation, broke, extended, and coalesced.
To this sore he applied a salve of beeswax and lard. A bubo soon formed
in his axilla, which subsequently subsided without suppurating. He next
noticed that, after a short period of fever, a series of papules appeared be-
tween his scapulas. This he thinks was within a week of the appearance
of the sores on his shoulder. The papules passed on to pustulation, and
then he observed the development of squamae and papuke in his scalp.
Then came enlargement of the post-cervical lymphatic glands, and three
papula? on his penis, with some on his scrotum.
At the time of our examination he has upon his right shoulder, cover-
ing the lower half of the star mentioned, a portion of skin of irregular
outline, about two inches in diameter, elevated one-eighth of an inch above
the general surface, indurated, of a coppery-red colour, and having near its
centre an ulceration still more elevated and about half an inch in diameter.
In his scalp are maculae, squamae, and papulae, the same on his forehead,
with a few papulae and pustulae distributed over his body. Upon his penis
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 49
are a number of papules within and without his prepuce, which is long
and indurated. He has sore throat, a fissure of the right angle of the
mouth, post-cervical adenitis and osteocopic pains.
This case may, perhaps, be one where the tattooing was the origin of
syphilis, but the appearance of the lesion on the shoulder and the almost
immediate appearance of the papular eruption between the scapulae make
us hesitate to come to such a conclusion. For this reason we prefer to
place it in this class, as though the sore which existed on his penis when
he was tattooed had been indeed a chancre.
Class III. Where syphilis had never existed, but vjas communicated
by the tattooing.
Case VIII George F. B., set. 17, Am., ice carrier; examined in
Reading, October 1, gives a good family history, and has had a healthy
life, excepting a fever when five years old, and gonorrhoea and gonorrhoeal
rheumatism four months ago ; both of which were cured before he was
tattooed. His habits have been free and easy.
About the middle of June, being quite well, he was tattooed on the
right forearm by Kelly. The figure chosen was a shield, with three dark
and two light bars. The pigments were India ink and vermilion. The
needles were constantly in Kelly's mouth. A slight local inflammation
followed, with reddening of the lymphatics up to his elbow, and glandular
involvement. By an application of glycerine and cold water the arm
healed, leaving, however, two weeks later five small elevations like mosquito
bites, upon which were crusts. These papules itched, were scratched, and
passed into pustules. They were treated some time later with a salve of
red oxide of mercury and dry application of calomel, under which they
healed. Five weeks after these sores the supra-trochlear gland became
enlarged. About three weeks later, ten after the tattooing, he noticed
squamae in his scalp, then a mucous patch came in his mouth, and a
contlylomatous patch between his buttocks. He has for five weeks been
under good specific treatment.
At the time of our examination he has a very few crusted papules in
his scalp ; a few scattered maculae over his chest and abdomen ; slight
post-cervical and inguinal adenitis ; some inflammation of the fauces, and,
on the left of his anus, a small slightly elevated condylomatous patch,
about a third of an inch in diameter.
Case IX — John N., get. 18, Am., brushmaker ; examined in Reading,
October 1 ; gives a good family and personal history ; has led a free and
easy, but not a hard, life.
About the end of May, being quite well, he was tattooed by Kelly on
the flexor aspect of his right forearm. The figure was a dancing girl on
an eagle, holding a flag in her hand ; the pigments, India ink and vermilion,
mixed with Kelly's saliva. There followed slight local inflammation,
accompanied by a red streak up the arm. After an interval of five weeks
there appeared at the lower inner corner of the flag a papule, elevated,
indurated, with an areola and itching. It was scratched and formed a
pustule, which persisted two months. Meanwhile it was once cauterized
with an acid, and simple soap applied. Four weeks later, nine after the
tattooing, there appeared a papular syphiloderm, most marked on his
scalp and scrotum.
No. CXLIX Jan. 1878 4
50 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
At the time of our examination we find his thighs a little marbled,
papules on his hands and feet, on his right buttock two medium sized
condylomata. The glands in his right groin are enlarged, and he has a
beautiful post-auricular adenitis.
Case X. — Cyrus S., ret. 2G, Am., boatman ; examined in Reading
October 2 ; gives a perfectly good family and personal history ; is an
occasional but not a hard drinker, and stands now a large magnificently
developed man, weighing 195^ lbs.
In June, being quite well, he was tattooed by Kelly on the back of the
right hand. The figure was a ten rayed star; the pigments India ink and
vermilion, mixed with Kelly's saliva. There followed a great deal of local
inflammation and an axillary bubo. He did nothing for this condition,
and in about a week, during its continuance, there appeared in the red
colour a lump which, he says, was " like a pill" under his skin. This was
painful, had an areola, itched, and was, as stated, indurated. It ivas
scratched, became covered with a crust, by repeated removal of which it
grew larger. In two weeks more, after a period of marked malaise and
fever, there appeared a papular eruption in his scalp, on his forehead and
face, in his nose, between his nates, on his penis, scrotum, palms and soles.
Between his nates the papules developed into condylomata with " terrible"
itching. In his mouth mucous patches also appeared. There were some
pustules among the papules on his hands, feet, and penis. He has been
of late under good treatment.
At the time of our examination, we find in his scalp and on his fore-
head and face traces of maculre and papules. His chest, abdomen, back,
thighs, and legs are beautifully clean. Between his nates are traces of the
former condylomata and a few papules. On the soles of his feet are scars
of many old papules. His fauces are erythematous. On his upper lip,
left side, is a small mucous patch. He has slight enlargement of the
submaxillary lymphatic glands, post-cervical adenitis most noticeable on
the right side, and marked alopecia.
Case XL — Jacob H., ret. 18, Am., examined in the Philadelphia Hos-
pital October 15, is a young man of good appearance, with a good family
and personal history. He says he has never had sexual intercourse.
About the beginning of June, being in perfect health, he was tattooed
in Reading by Kelly. The figure of an eagle with a scroll in its beak,
surmounted by a crown and two letters, was placed on the flexor aspect of
his right forearm. The pigments, India ink and vermilion, were mixed with
Kelly's saliva alone. There followed scarcely any local inflammation. In
about seven weeks there appeared on the right wing of the eagle two
papules, which he compares to mosquito bites, developing into pustules,
and soon followed by one on the crown and two on the scroll. There
came in a short time a red streak extending up toward the axilla, and an
axillary bubo. The pustules he burnt with nitrate of silver, and got some
medicine from a doctor. Five weeks after the appearance of the papules
there appeared a papule on his penis, then two on his scrotum, a few about
his anus, a few on his head, and three on his left hand, with soreness of his
gums and throat. About six weeks ago, when in the condition just de-
scribed, he was treated locally and constitutionally with good results.
At the time of our examination he has two or three nearly cured papules
in his scalp, and as many in his left palm. His fauces are deeply inflamed
and swollen ; his gums inflamed and ulcerated ; he has alopecia and en-
largement of the inguinal glands on both sides.
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 51
Case XII. — Edward TV., jet. 20, Am., wool-washer ; examined, by
courtesy of Prof. TVm. H. Pancoast, in the Philadelphia Hospital Sept.
21, and repeatedly afterwards; gives an unexceptionable family history,
and has always been healthy until last spring, when he had an attack of
typhoid fever, which was treated in this hospital. He has been of steady,
temperate habits, and never had any venereal disease.
About the end of June he was tattooed by Kelly, upon the flexor aspect
of the left forearm. The figure was a goddess of liberty seated upon an
eagle, and bearing an American flag; the pigments were India ink and ver-
milion, mixed with pure water. The operation was followed by a mode-
rate and transient degree of local inflammation without any involvement
of the lymphatics. Two weeks before this he had been tattooed by the
same man on the flexor aspect of the right arm with the figure of a cruci-
fixion. On the radial side of the figure and in the background were two
oriental looking buildings, and on the ulnar side a small tree. The pig-
ments, coal-dust and vermilion, were mixed with Kelly's saliva. The
arm soon became extremely inflamed and swollen. This inflammation,
however, subsided in four or five days, and he observed no involvement of
the lymphatic vessels or glands.
In about a month there appeared on the ulnar side of the base of the
figure, a papule, which he compares to a mosquito bite. It itched much,
was" scratched, became purulent, and enlarged until there was a circum-
scribed ulceration three-quarters of an inch in diameter, with a flat, some-
what elevated, indurated base, and a well-defined areola. This process
the patient watched carefully and describes accurately. At the time of
the development of the papule the glands of the right axilla became en-
larged. Six weeks later, about ten after the tattooing, a macular syphilo-
derm developed upon his forehead, chest, belly, and legs, in this order,
followed by a mixed squamous and papular syphiloderm.
At the time of our examination the patient. appears in excellent general
condition. He is a stout, well developed, healthy looking young man.
The ulcer described still persists on his right arm. On his forehead is a
light, brownish syphiloderm. There are papules in his scalp, a few on
his arms and back, very many on his palms and soles, and about his anus
many passing into condylomata. His scrotum is so thickly covered with
flat papules that it is hard to discover any interspaces. There are very
many on his penis. Within the prepuce these are excoriated and closely
simulate chancres in a similar stage. On his thighs are some pustules as
well as papules. He has also distinct right-sided post-cervical adenitis.
Case XIII Joseph P., ret. 20, Am., iron moulder; examined in
Reading October 1. His family history is perfectly good. About a year
ago he had inflammatory rheumatism, lasting ten weeks. He has never
had any venereal disease. His habits have been regular and steady.
In June, being perfectly well, he was tattooed on the flexor aspect of the
right forearm, by Kelly. The figure was a 2, upon which lies a ladder.
The pigments were India ink mixed with water, and vermilion mixed
with Kelly's saliva. There followed slight local but no glandular inflam-
mation. This received no treatment. In about three weeks appeared a
papule, elevated, indurated, and itching. This was scratched and developed
into a pustule, which enlarged to about a half inch in diameter. It was
treated with lead-water and laudanum, then later with lotio nigra and
calomel, while he took some internal medicine.
Ten days after the appearance of the papule, without preceding fever,
52 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
the lymphatics of his arm became red and his axilla tender. Then appeared
a macular and squamous syphiloderm, followed by papules around the
corona glandis penis, and along the raphe, with a mucous patch in his
mouth, swelling of the papillae of the tongue, and sore-throat.
At the time of our examination the patient complains of indisposition,
with pains in his back and stomach. Old maculae are distributed over his
scalp and legs ; on his back, penis, and scrotum are a few papules, and
many in his palms and soles. On the inside of the right check is a small
mucous patch. His submaxillary, postcervical, and inguinal glands are
enlarged, and he has some alopecia and sore-throat.
Case XIV. — Charles P., a?t. 19, Am., japanner; was examined in
Reading October 1. His family history is good. Four years ago he had
typhoid fever; three months ago — since being tattooed — he had gonorrhoea.
He says his habits have been regular, and he is not addicted to excessive
venery.
About the middle of June, when in perfect health, he was tattooed on the
flexor aspect of the right forearm, by Kelly. The figure is very large and
thickly coloured. It represents a naked woman kneeling on a pedestal,
under a dense weeping willow7 tree. The pigments, India ink and ver-
milion, were mixed with Kelly's saliva,. For a week the arm was very
sore, and a gland in the axilla swelled, but soon subsided. To the arm
cold water was applied. In about two weeks appeared on the figure a
single papule, which had a distinct areola, was indurated, elevated, and
itched ; yet was not scratched. It developed into a pustule, ruptured,
became encrusted, and healed in two weeks without treatment. About
two weeks later appeared, below the figure, a flat papule, accompanied by
an axillary bubo. At the same time came a general macular syphiloderm,
which desquamated and was succeeded by papules, which were profuse on
his penis — he thinks there were seventy-five ! He also had condylomata
between his toes. At the time of our examination — three and a half months
after his tattooing — he has macula? and squama? on his scalp, and a well-
marked corona veneris. There are papules on his chest, back, arms, legs
(arranged in circles in the popliteal spaces), penis, scrotum, and soles. In
his nose are crusted papules, on the right side of his uvula is an ulcer. The
corresponding submaxillary gland is enlarged. He has also bilateral in-
guinal adenitis and well-marked alopecia and sore-throat.
Case XV Thos. G., set. 23, Irish, iron puddler ; examined in the
Philadelphia Hospital September 21, gives an unexceptionable family his-
tory ; has had no serious illness before, nor any venereal complaint. ; has
been a steady, but not a hard drinker.
About the middle of June — at a time when he was under treatment in
the Philadelphia Hospital for traumatic orchitis, but otherwise well — he
was tattooed by Kelly on the flexor aspect of the left forearm. The figure
was that of a cross upon which was a wreath and a heart. The pigments,
coal-dust and vermilion, were mixed with fresh water. Following the
operation there was some soreness of the arm, lasting two days, and
enlargement of the axillary lymphatic glands. Both these subsided readily.
Three days previous to this tattooing Kelly had put on the flexor aspect
of his right forearm the figure of a crucifix, with a background of t wo
oriental looking buildings on the radial side, and on the ulnar a small tree.
This time the same pigments were moistened with Kelly's saliva. The arm
became much inflamed, and the next day a gland above the internal
condyle of the humerus and one in the axilla were enlarged ; of these the
1878.] Macry, Dulles, Syphilis Communicated by Tattooing. 53
former subsided soon. The local soreness lasted three days, but required
no treatment. About five weeks later, at a point upon the trunk of the
tree alluded to, appeared two papules — which he compares to mosquito-
bites. These developed into pustules, with indurated bases, burst and
coalesced, leaving an elevated suppurating surface, about three-fourths of
an inch in diameter, with a distinct areola, which he treated, himself, with
cosmoline and iodoform. About this time the bubo in the axilla suppurated
and discharged spontaneously. About ten weeks after the tattooing, and
five or six after the appearance of the sore just described, he had a short
period of feverishness and indisposition, and then appeared a papular
syphiloderm, accompanied or followed by a fissure of the right angle of
the mouth.
At the time of our examination he has papules on his scalp, back, arms,
penis, scrotum, nates, legs, palms, and soles, as well as between his toes.
The number on his palms is very remarkable. On the cutaneous surface
of his prepuce are papules, closely resembling hard chancres, while on the
mucous surface are ulcerations simulating chancroids. The fissure of the
right angle of the mouth persists. He is suffering from a balanitis and
gonorrhoea contracted recently. He has post-cervical adenitis, and is in a
very much poorer general physical condition than he ever was before the
tattooing was done.
Case XVI. — Frederick R., aBt. 21, Am., brickmaker ; examined in the
Philadelphia Hospital September 25; gives a good family history; has
been of tolerably steady habits ; many years ago had an inguinal bubo,
from over-walking ; four years ago had gonorrhoea, from which he inocu-
lated his left eye with gonorrhoeal ophthalmia, resulting in its almost total
destruction. About the end of May he was tattooed by Kelly. On the
dorsal aspect of the left forearm was placed a dancing girl, and near it a
cross, heart, and anchor. On the inner side of the upper arm was placed a
goddess of liberty on an eagle. The pigments, India ink and vermilion, were
mixed with Kelly's saliva. The day following his arm was much inflamed,
and a bubo formed in the axilla. Both the inflammation and the bubo
passed away in a few days. A gland below the inner condyle of the
humerus now became enlarged and painful, and then subsided. Four
weeks from the date of tattooing there appeared two swellings, one above
the right knee and one on the left foot of the figure of the dancing girl.
These he compares to a boil, with pus at the apex. They itched, were
scratched, and crusts formed upon them. Later, appeared a fissure of the
left angle of his mouth, and papules on his tongue, penis, and scrotum,
and about his anus, as well as one or two on his left palm and one on his
right foot. At our examination we find on his body traces of a macular
syphiloderm ; about his anus are three patches of ulcerating hypertrophic
papules ; two similar patches on the left and one on the right side of his
scrotum; traces of two healed patches also on his scrotum; one such patch
in each thigh ; and one on the right calf ; his pharynx and fauces are in-
flamed ; his tongue swollen and fissured ; a mucous patch inside the left
angle of his mouth and one inside the lower lip. His eyes are inflamed,
and seem to threaten iritis. He has post-cervical adenitis.
Case XVII — Daniel II., aet. 21, Am., labourer ; examined in the
Philadelphia Hospital September 26 ; gives a family history of phthisis,
himself has always been healthy and of steady habits, though an occasional
drinker ; has never had any venereal disease. A year ago he was tattooed
on the right forearm. No evil results followed.
54 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
In the latter part of May of this year he was tattooed by Kelly on the
dorsal aspect of the right forearm. The figure was a goddess of liberty
upon an eagle; the pigments, India ink and vermilion, mixed with Kelly's
saliva. He was at the same time tattooed in the same way, on the left arm,
with the figure of a little girl holding a bouquet in her left hand. Both
these figures were followed by great local pain and swelling, and involve-
ment of the axillary glands. The latter, however, subsided in a few days.
In about three weeks there appeared on the figure on his right arm, and
later on the other, a number of papules, which multiplied until on the former
there were seventeen and on the latter twenty-four. In the latter case the
papules appeared wherever the vermilion had been used. The first appear-
ance of these papules the patient compares to mosquito bites. They were
indurated and elevated, and had an areola; they itched, Avcre scratched,
became purulent, and formed crusts. A number of them were cauterized
by a physician, an ointment applied, and they healed up in about a fortnight.
The rest healed spontaneously. No axillary bubo followed. About the
middle of July, about six weeks after the tattooing and three after the first
syphilitic manifestation, a papular eruption appeared on his scalp, penis,
scrotum, palms, and soles, and in his nasal cavity and external auditory
canals. Later, on his forehead and lips was developed syphilitic impetigo.
In three months from the time of tattooing mucous patches appeared in
his mouth. Since the early cauterization he has been treated with roots"
by a snake doctor. At our examination we find many desquamating papules
in his scalp, a few large papules on his abdomen, three smaller ones around
his corona glandis penis, one on the frenum, four on the scrotum, nine on
his thighs, one in the left popliteal space, and the traces of very many on
his palms and soles. On his forehead are four beautiful crescentic patches
of impetiginous pustules, and on his lips several more. His lips and mouth
are covered ♦with mucous patches, and about his anus he has immense
condylomata.
Case XVIII John G., net. 16, Am., machinist ; examined in the
Philadelphia Hospital September 29 ; his family and personal history is
excellent. About the end of May, when in perfect health, he was tattooed
in Reading by Kelly, on the flexor aspect of his right forearm. The figure
was that of a dancing girl; the pigments, India ink, mixed with water,
and vermilion, mixed with Kelly's saliva. After pricking in the colors,
Kelly spit on the patient's arm and rubbed it well. Slight and transient
local inflammation followed, for which cold water was applied, but there
was no glandular swelling. In four weeks there appeared on the left
shoulder of the figure a papule, indurated, itching, and having an areola,
followed, the next week, by six similar ones, scattered over the figure.
They all developed into pustules under the influence of scratching. He
now received treatment, which he describes as a salve and powders. Two
weeks later, six after the tattooing, without preceding fever, a number
of small lymphatic glands below the elbow-joint enlarged, and a lymphatic
vessel, running from them to the axilla, became hard, like a whip-cord.
These conditions persist at this time. He next noticed a papular eruption
on the soles of his feet, with a few papules on his back and neck, the latter
developing into pustules. He now treated himself with gin and mandrake
roots. At the time of our examination, a little more than four months after
his tattooing, we find his scalp clean, patches of copper-coloured spots
on his forehead, papules in his nasal cavity and right external auditory
meatus, on his face, a few on his chest, several hypertrophic and encrusted
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 55
on his abdomen, one in his right axilla, quite a number of medium size on
his back and buttocks, many on his arms, penis, scrotum, thighs, shins,
and both soles. There are a few pustules on his back. Between his nates
are three condylomatous patches, and others between the toes of both feet.
He has slight erythema of the fauces and a large mucous patch on the roof
of his mouth. He has not very well-marked post-cervical adenitis.
Case XIX Alvin S., aet. 20, Am., teamster; examined in the Phila-
delphia Hospital September 29; gives a perfectly good family and personal
history, except that he had, in 1875, a gonorrhoea lasting seven months,
and in 1876 another attack which was cured in two weeks; his habits
have been pretty steady, though occasionally indulging in venery.
About the end of May, 1877, being perfectly well, he was tattooed by
Kelly on the flexor aspect of his left forearm ; the figure was that of a
dancing girl ; the pigments India ink mixed with water, and vermilion
mixed with Kelly's saliva. There followed a slight local inflammation
lasting but two days, and presenting no involvement of the lymphatics,
which he did not think demanded any treatment. Two weeks from the
tattooing there appeared on the breast of the figure three papules, then
two more on the left lower part of her scanty dress, and a week later on
the crossed ankles another. These were hard, elevated, and red ; spread
into flat papules, desquamating somewhat, and finally secreted a little
pus. Soon after their appearance they were cauterized, and the patient
constitutionally treated by a regular practitioner. In about two weeks,
without any preceding fever, there appeared upon his legs below the
knees, a squamous syphiloderm, followed by many papules and pustules
on his thighs, scrotum, and penis. Of the latter some were excoriated.
About the same time he noticed an enlargement of the left supra-trochlear
gland. For this stage of the disease also, he was treated constitutionally.
At the time of our examination he had a gonorrhoea two weeks old ; in
his scalp are many maculae, and a few on his chest and shins ; there are a
few papules on the side of his nose, and some encrusted ones in its cavity,
many on his thighs, and a number on both soles. There are a few pus-
tules on his back — perhaps acne. Between his nates are two condyloma-
tous patches, and others between the third and fourth, and fourth and fifth
toes of the right foot. He has erythema of the fauces, an ulcer on the
right side of the uvula, mucous patches on the edge and lower surface of
his tongue, very large ones inside the angles of his mouth, and smaller
ones within both lips. One seems to be developing on the roof of his
mouth. He has marked submaxillary adenitis, alopecia, and left iritis.
Case XX — James F. P., aet. 25, American, iron moulder; examined
in Reading October 1 ; gives a good family and personal history, except
that two years ago he had an attack of gonorrhoea which lasted four
months. His habits have been pretty good, and he never drinks. Years
ago he had a suppurating bubo in the left groin from an ingrowing nail.
He was tattooed by Kelly about the middle of June, being then perfectly
well. A female bust was placed upon the flexor aspect of his right fore-
arm, and above it two crossed branches. The pigments, India ink and
vermilion, were mixed with water and Kelly's saliva, the needles being
frequently put in his mouth. There was slight and transient local inflam-
mation, and no glandular involvement. He applied cold water to his
arm. In four weeks there appeared upon the tattooed figure, many small
papules, which were not sore nor purulent, nor have they ever been
abraded or excoriated, though now having a tendency to scale a little.
56 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
They received no treatment. In about six weeks from the date of tattoo-
ing, there appeared on his forehead and penis a papular eruption, then
later mucous patches on the tip of his tongue and the sides of his gums.
For these he had no treatment.
At the time of our examination we find a few papules on his body, and
between his nates, two on his corona glandis penis, crescentic patches in
his popliteal spaces, a few on his knees, shins, and ankles, his palms and
soles crowded with them. In his mouth are a number of mucous patches.
He has post-cervical, submaxillary and inguinal adenitis, with marked
enlargement of his right supra-trochlear gland, and one behind his left
ear. He has also alopecia and osteocopic pains.
Case XXI George H., a?t. 23, American, laborer ; examined in Read-
ing October 2 ; gives a good family and personal history; has been of some-
what irregular habits, but not a hard drinker. About the end of May, being
quite well, he was tattooed by Kelly on the left forearm. The figure was
a goddess of liberty with a flag, and two crossed branches below ; the pig-
ments were India ink mixed with water, and vermilion mixed with Kelly's
saliva. Kelly also spit on the arm and rubbed the colours in. There was
considerable local inflammation, but it was treated simply with soap and
water. In about two weeks there appeared a papule in the middle of the
crossed branches, and in two days three more near by. They developed
into pustules and formed deep ulcers which were treated and healed in
three weeks. The scars persist, and are about half an inch in diameter. A
month after these papules he had a period of fever with marked malaise,
followed by a general erythematous eruption, then maculae and squama}
on his chest and shins, followed by papules on his head and forehead, in
his nose, on his arms, legs, palms, and soles, and between his toes. Later
he had mucous patches in his mouth and condylomata about his anus.
At the time of our examination we find a few macula? on his chest.
There are traces of very many small papules on his forehead. Papules in
various stages of development or recession are distributed over his back,
abdomen, thighs, popliteal spaces, shins, ankles, palms, and soles. On his
left arm is a fine crust from a vaccination done twelve days ago. On the
tattooed figure of liberty are scars of the four pustules named above. His
fauces are red and ulcerated; on the roof of his mouth are large mucous
patches, and others on his gums. His tongue is swollen, ridged, and fur-
rowed, and has on its left edge a mucous patch. The supra-trochlear
glands in both arms are enlarged. His general condition is bad ; he is
sleepless and miserable, suffering much with osteocopic pains.
Case XXII William L., a?t. 21, Am., butcher; examined at the
House of Correction Oct. 25 ; gives a good family and personal history ;
is of healthy general appearance. His statements are clear and positive.
In September of last year, on the occasion of his twentieth birthday, he
drank, and had intercourse with a prostitute. Ten or fifteen days later,
without any other exposure, he noticed, on the left side of his glans penis,
a sore, which a friend told him was a " chancre." This soon became an
ulcer, and he got some nitrate of silver and cauterized it. He took no
other measures in this connection. The crusts which formed upon the
ulcer adhered to his shirt, and were a number of times pulled off. Once,
Avhen the sore was a week or two old, he had intercourse with a woman,
and the crust came off and remained in her vagina. In a few weeks the
ulcer healed. Upon careful and exhaustive inquiry he states that he had
no subsequent lymphatic or cutaneous evidence of syphilis. However, he
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 57
suffered all the following winter with tonsillar enlargement, which he be-
lieved to be mumps, and which was much relieved by a gargle of vinegar
and cayenne pepper. In February of this year — five months after the
sore on his penis — there appeared on the outer aspect of his right thigh,
about nine inches below the position qf the trochanter major, a sort of a
blister, which spread to a diameter of about an inch and became encrusted.
Some weeks later a similar but smaller ulcer formed six inches higher
on his thigh. After trying in vain to heal it by poulticing he went, on
April 27, to the Philadelphia Hospital, where he was admitted to the
venereal ward. Here the sores were diagnosed as syphilitic rupia ; the
crusts, which are described by the interne, Dr. Oliver, as like a tortoise-
shell and of a dirty blackish-brown colour, came off; local cauterization
with nitric acid was used, and the protiodide of mercury administered
internally. In about a month the ulcers were healed.
About the end of June, while acting as an assistant in the hospital, he
was tattooed by Kelly on the flexor aspect of the left forearm. The figure
was a crucifixion, the pigments India ink and vermilion, both of which
were moistened solely with the tattooer's saliva. There followed slight and
transient local inflammation, requiring no special treatment. In ten days
he noticed three sores upon the tattooed figure, one on the right hand, one
on the left shoulder, and one on the left wrist. These, he says, were like
the bite of a "mosquito or bedbug." They itched, but were not scratched for
fear of "poisoning" them. They soon secreted pus, and became ulcerated.
In about a week an axillary bubo formed. He now became alarmed, and
consulted Dr. Oliver, who describes the sores as small papules, situated
on a plainly indurated base, with an areola which faded out toward the
circumference. They soon developed into pustules, and later into excavated
ulcers, which were cauterized with nitric acid, after which they became
encrusted. At the time of cauterization he was .placed upon anti-syphilitic
treatment. He now permitted Kelly to tattoo both his upper arms, but
made him mix his pigments with water. No evil results followed these
operations. He noticed no evidences of secondary syphilis until two
months later, when there appeared papules in his nose and mucous patches
in his mouth.
At the time of our examination, four months after the tattooing, we find
on his left forearm three hypertrophic papules covered with thick adherent
scales, and surrounded by areas of thin bluish skin. These are the remains
of the primary lesions described above, and are the exact counterpart of
what we found on many of the other patients of this class. On his body
are remains of a beautiful macular syphiloderm, of which he says he was
not aware when it came. There are some papules in his nose, and many
in his palms and soles. He says there have been none on his genitals.
He has mucous patches in his mouth ; an extensive one over the ascending
ramus of the right maxilla inferior ; one on the right side of the lower lip ;
and a number of small ones on the roof of his mouth. The only adenitis
we can find is atrifling enlargement of both supra-trochlear glands ; perhaps a
slight enlargement of the right inguinal glands, and in his left axilla remains
of the bubo. He has marked alopecia, and complains of severe muscular
pains as well as of pains in his bones. On the left side of his glans penis
is a small teat-like scar, which when pinched gives a feeling of slight in-
duration. Upon his right thigh are the scars of the sores which he con-
nects with his chancre acquired in September 1876. The lower or earlier
one presents a thin-skinned, elevated, slightly indurated, ham-coloured
58 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
surface, oval in shape, about three-quarters of an inch in its longer, and
half an inch in its shorter diameter, having extending to a distance of half
an inch from its margin, all round, an areola of thin dusky skin. The
upper or later lesion is similar in character, but smaller. The inner ele-
vated and indurated part is less than a centimetre, and the total, including
areola, about half an inch in diameter.
There is some difficulty in assigning this case its proper place; but we
conclude it is one where syphilis was communicated by the tattooing, in
spite of the singularly clear and honest statement of the patient in regard
to his previous history, and in spite of the scar on his penis, the sore-
throat, and the appearance of the lesions occurring after what he himself
believed an infecting or true chancre, and which he believed to be syphilis.
This conclusion depends upon the patient's positive and distinct statement
that these two, the sore-throat and the ulcers on his thigh, were the only
things simulating secondary syphilis which he observed. lie had after his
chancre no bubo, no eruption, no crusts in his head, no alopecia, no iritis.
When to this we add the history and appearance of the lesion which fol-
lowed his tattooing, and the condition in which he is at the time of our
examination, we are brought to the conclusion, partly stated above, that
his lesion last September was a chancroid — not a chancre — that his sore-
throat was probably a tonsillitis, and that the ulcers in his leg were prob-
ably ecthyma, and not rupia, as at first sight they might appear. Conse-
quently we include the case among those in which syphilis was for the
first time communicated by the tattooing.
Resume. — These fifteen cases of Class III. present a number of points
of great interest which we will examine, so far as possible, in their natural
order.
The first of these points is in regard to the method of inoculation. In
every case we find that the needles used for tattooing were repeatedly in-
serted in Kelly's mouth ; saliva was used to moisten at least one of the
pigments. Can we then say the saliva was the contagion? No; for we
find equally that all the cases in Class I., who never had syphilis, and
present as yet no evidence of it since their tattooing, were exposed to ap-
parently as great risk of infection ; and must conclude that we have not
here any ground to doubt the general belief that the unmixed salivary
secretion cannot communicate syphilis.
On the other hand, the existence and the special location of the mucous
patches in Kelly's mouth seem to offer a reasonable and satisfactory ex-
planation of the effects of his tattooing. Nothing is more probable than
that, in the repeated application of the needles to his lips, the sucking, the
wetting of them, they in most cases bore away virus from the lesions
which were so conveniently situated for this ; while, also, nothing is
easier to suppose than that the immunity in some cases was due to the
fortuitous absence of this virus.
A question might suggest itself as to the influence of tobacco juice
1878.] Maury, Dulles, Syphilis Communicated by Tattooing. 59
mingled with the virus. From our examination of the cases here given
we are led personally to the opinion that it did not have any, either in
diminishing or increasing its activity.
In Cases XII. and XV. we have beautifully contrasted the innocence
of tattooing with water, and the serious result when the saliva was used.
We frequently observed that when one pigment was mixed with water and
the other with saliva, the primary lesion had its origin unmistakably where
the latter was used.
In the immediate effects we find considerable variety, but in none any
specific evidence of a constitutional infection ; this comes out first with the
appearance, after a period of incubation varying from one to seven weeks,
of a lesion which is of the utmost interest for us.
What ivas this primary lesion ? Our inquiry (in which we particularly
avoided asking leading questions) secured answers which, though varied,
were unmistakable. Some compared the first manifestation to a pimple,
some to a mosquito or bedbug bite, and one to "a pill under the skin;"
all presenting the essential characteristics of local swelling and induration
which mark a papule. In most cases this papule, like any other of its
class, passed on, under accidental influences, to excoriation, ulceration, or
pustulation; yet in one remarkable instance (Case XX.) there were none
of these modifications, but from first to last only and simply papules.
In other words, these cases present a beautiful illustration of the nature
and progress of a chancre, which we would define as in the beginning a
papule excited by a specific irritant, undergoing modifications as varied as
the circumstances in which it is placed, and followed sooner or later by
other manifestations of syphilis. (This is the only sense in which the
term is used by us.)
The theory of Diday, that the initial lesion of syphilis, contracted from
the virus of a secondary manifestation, is an excoriated sore as contrasted
with the ulcerated form when the poison was primary, does not seem sup-
ported by the facts of this series of cases ; for, on the contrary, we find
every variety, from the simple, unabraded papule to the deep and multiple
ulcer.
The multiplicity of the initial lesion in some of these cases is not re-
markable when we consider the means of inoculation.
The varying terms of incubation of the primary lesion — from one to
seven weeks — as well as those of the secondary manifestations — from one
to six weeks more — may or may not have been what the patients stated.
We have no means of correcting their statements, and can only reproduce
them with this explanation, and without attempting any generalizations
founded upon them.
After the appearance of the initial lesion there was, then, a period of
incubation varying, as the patients believed, from one week to six weeks,
followed by —
60 Maury, Dulles, Syphilis Communicated by Tattooing. [Jan.
The manifestations of "secondary" syphilis In three cases these
were ushered in by fever and malaise ; in one the glands just below the
bend of the elbow were enlarged; in five the supra-trochlear gland (gland
of Ricord). In three cases there was reddening, and in one persistent
whipcord-like induration of a lymphatic vessel. In six cases the glands
in the axilla were involved. It is noticeable that in one case the axillary
bubo suppurated and discharged spontaneously — an example of the rare
but possible occurrence of a suppurating bubo following a chancre. There
were four cases in which we could not satisfy ourselves of the implication
of near lymphatic glands.
Following or accompanying this stage we find the manifestation of
syphilis on the cutaneous and mucous surfaces. Of the earlier and more
transient forms — erythema, macular, and squama? — we found it in some
cases difficult to obtain any satisfactory evidence ; in some, however, we
found distinct traces, though the patients themselves had not been aware
of their occurrence. But when we looked for the papular eruptions there
was no such difficulty. The history was well impressed on the patients'
minds, and the present evidence often only too obvious. A glance over
the summary shows that these were, in most cases, of an extremely grave
character. In twelve of the fifteen cases there were mucous patches or
ulcers in the mouth. In one the patches were very numerous, and in two
both numerous and extensive. In one case there was a fissure of the angle
of the mouth. In ten cases there were condylomata, which were, in one
of them, immense. In one case there was well-marked impetigo on the
forehead and lips. In one there was iritis ; in nine post-cervical, in two
post-auricular, in six inguinal, in five submaxillary, adenitis. In seven
cases there was alopecia, and in three osteocopic pains.
A noteworthy point seems to us the frequency with which the papules
were located on the penis and scrotum. This occurred in twelve cases, in
seven of which the number was very great. In many the papules situated
on and within the prepuce, and about the corona glandis penis, were in
their physical features exactly like chancres. (See, for example, Case
VII.) In twelve cases there were papules developed in the soles, and in
ten in the palms. In seven they were developed in the nasal cavity,
becoming a cause of grave annoyance. In two there were papules in the
external auditory meatus.
The result of auto-inoculation, practised on two patients who had plain
manifestations of syphilis, was as follows : —
Case XV — On September 19th we scraped, with a tenotome, a little
secretion from the primary lesion on his right arm, and inserted it in his
left upper arm by scarification. This was covered with a watch crystal,
held in place by a fenestrated band of adhesive plaster.
The second day there was a slight reddening of the part scarified, and
apparently a little thin serous secretion under the glass. The third day
both these seemed greater. The fourth day the epidermis was elevated and
1 878.] Maury, Dulles, Syphilis Communicated by Tattooing. 61
macerated, and a superficial ulceration, about a sixth of an inch in diameter,
beginning. Over this was the grayish-white coating of epidermis ; around
it was a narrow areola. It was moist, and gave material pain. The
fifth clay the areola was less; the ulcer about the same. The sixth day
there was scarcely any areola ; but the* ulcer was deeper. The seventh
day the areola was apparently unchanged ; but the ulcer acquiring an
irregular edge, and having a thin deposit covering it. The eighth day
the ulcer was reduced in size, and the areola had disappeared. The
ninth day no observation was made. The tenth day the ulcer was almost
healed ; but the patient complained of much pain. So the glass was
removed, and we found its upper and lower edge had cut into the skin,
making with the irritation of the secretions of the ulcer, two others,
linear and ugly, each about three-quarters of an inch long, and just like
their predecessor in character.
As we did not think the study of these would add any material point
to that of the one we had made designedly, we applied to them, and the
trace of it that was left, lotio nigra, under which all healed up nicely in
three or four days more.
Case XII On September 25th Ave scraped off, with a tenotome, a little
of the secretion of the primary lesion on his right arm, and attempted to
insert it in the left forearm by a simple puncture, in which we turned the
point once around. In covering the spot with a watch glass we avoided
the danger of producing such trouble as we had in the other case, by in-
closing the glass between two fenestrated strips of plaster, placed face to
face, of which the outer or upper was longer than the inner, and tailed —
the tails serving to fix the whole, and keep it in position.
The patient was under observation for about two weeks longer, at the
end of which time he eloped from the hospital. So far the result was
entirely negative, save perhaps an insignificant reddening of the point of
puncture the day after it was made.
In reviewing these two cases, we find, in the former the virus from a
primary syphilitic lesion — a chancre — producing by auto-inoculation an
ulcer presenting the features of a so-called chancroid.
Upon the apparently negative result in the second case we do not think
anything can be predicated, for the time of observation was too limited ;
and, besides, we have no right to assume that the inoculation was success-
fully executed.
The theoretical conclusions of our investigation are, we think, indis-
putably confirmatory of the view that the virus from secondary syphilitic
manifestations is* in a high degree inoculable, that the primary lesion
following such inoculation is a true chancre, and that with this begins
constitutional syphilis, differing in no essential point from that contracted
from a primary syphilitic lesion.
The practical conclusions are inseparable from the theoretical, viz., that
too great caution cannot be used lest by any means the virus of inoculable
lesions be transferred to innocent persons. The hands of the surgeon, his
instruments, bandages, or other appliances should be most scrupulously
cleaned after use about syphilitic patients. Dentists may especially take
to heart this lesson, which is the more deeply impressed upon our minds,
G2 Poore, Disease of the Sacro-iliac Synchondrosis. [Jan.
because, at this time, we are investigating a case where an unsuspecting
woman was inoculated with syphilis of a most malignant type, while under
a dentist's hands.
Tattooing, we think, might well be forbidden in the army and navy, as
a useless and perhaps pernicious practice, one which may injure the men
and prove an expense to the government, by bringing into hospitals and
on the pension lists some who might otherwise be in active service.
We think, too, that no false sentiment should prevent the distribution
of such warning to the community as shall acquaint them with the sources
of danger alluded to, as well as the possibility of syphilitic inoculation in
the acts of kissing, nursing, using in common table utensils, towels, or
anything which may come into contact with a syphilitic lesion.
Article III.
Disease of the Sacro-Iliac Synchondrosis. By Charles T. Poore,
M.D., Surgeon to St. Mary's Free Hospital for Children, and to Charity
Hospital, New York.
Case I A. B., aged four years, was admitted into St. Mary's Free
Hospital for Children January 31, 1877. She is a perfectly healthy look-
ing child. Family history good. Her mother gives the following account
of her illness. Last August she began to limp a little, especially when she
walked fast or attempted to run ; at this time she did not complain of any
pain. Four weeks later she complained of pain in her left knee. She
was then seen by a physician, who said that she had disease of the left
hip-joint. During the winter her lameness gradually increased, and
another physician who had charge of her inclined to the opinion expressed
by the former attendant, although he stated that there was an absence of
any tenderness, heat, or swelling about the joint. On admission, the
following was her condition. There was no change in the contour of the
parts about the left hip-joint ; no atrophy of the muscles. Motion at the
hip-joint was perfectly free, smooth, and painless, except when carried to
extreme rotation inwards or outwards, or forced flexion, when she com-
plained of pain between the trochanter major and the sacro-iliac joint, and
at the knee. There was no lordosis when the thigh was extended on the
pelvis, and no tilting of the latter. Pressure on the trochanter major, or
striking the sole of the foot with the limb in an extended position, caused
pain behind the hip-joint. Pressure on the left ilium, either at right
angles to the body, or backwards, caused pain at the left sacro-iliac
synchondrosis. There was pain on pressure over the left sacro-iliac joint.
She complained, when up, of pain on the outer aspect of the left thigh,
lower portion of left leg, and at the knee. There was no swelling or
tenderness over the hip-joint below Poupart's ligament, nor behind the
trochanter major. When in bed she could flex, extend, and rotate the
thigh without any pain. In walking there was nothing characteristic in
the way she carried herself, except that she threw the weight of her body
on the sound side. When in bed she had no pain day or night, but always
1878.]
Poore, Disease of the Sacro-iliac Synchondrosis.
63
suffered when on her feet in the localities mentioned above. There was
no real, or apparent, difference in the length of the lower limbs.
March 29. Has been kept quiet in bed. To-day extension was applied.
April 4. Since the 29th she has been crying much from pain in the
left thigh, knee, but especially about %the lower portion of her leg. On
removing the weight it passes off, only to appear when the extension is
put on again.
23c/. Piaster of Paris bandage applied around the pelvis, but it had to
be removed in a few days on account of the pressure.
June 6. Patient fell out of bed last night, and to-day complains of pain
in her left thigh, and upon motion; the parts are swollen and tender.
7th. She was to-day removed from the hospital.
Case II — D. W., aged five years, was admitted into St. Mary's Free
Hospital for Children April 7, 1877. The following imperfect history is
all that could be obtained. Last October he complained of pain at in-
tervals about his right hip, which gradually increased. He became lame,
and was supposed to have disease of the hip-joint. He has always rested
well at night, and suffered no pain when in the recumbent position. There
is no history of any foil or injury. On admission, the following was his
condition. When standing there was a marked difference in the contour
of the hips : the right was bulged out, so as to form a curve beginning at
the lower ribs, having its greatest point of convexity just below the crest
of the ilium, then curving inwards and ending at the lower border of the
nates on that side, which was lower, and more pointed than on the left
side. This bulging out was caused partly by his position, and partly by
an abscess which occupied the gluteal region. The right limb was
atrophied, as well as the muscles forming the gluteal group. Motion at
the hip-joint was perfectly free, smooth, and painless, except in forced
flexion and rotation, when he complained of pain at the sacro-iliac joint.
There was no lordosis when the thigh was extended on the pelvis. Pres-
sure on the trochanter major, or striking on the sole of the foot, when the
limb was extended, caused pain at the right sacro-iliac synchondrosis, and
any movement of the ilium of that side on the sacrum caused the patient
to cry out from pain. There was exquisite tenderness over the right
sacro-iliac joint. The patient could flex, extend, and rotate the limb
Avhen in bed. There was no swelling or tenderness over the joint below
Poupart's ligament, nor behind the trochanter major. He did not com-
plain of any pain day or night when in bed, but standing and walking
were almost impossible on account of the pain. He complains of no pain
in the thigh, knee, or leg.
April 9. Abscess in gluteal region aspirated, but only a few ounces of
pus obtained.
o^th. Several attempts have been made to evacuate the abscess by
aspiration, and, although several ounces of pus have been removed each
time, yet the abscess did not seem to be emptied. To-day a free incision
was made through the gluteal muscles, and eight or ten ounces of matter
evacuated : there seem to have been two abscess cavities, one superficial,
the other deep below the gluteal muscles, and in aspirating only the former
was reached. For the past week the thigh has gradually become flexed
on the pelvis, and cannot now be extended to more than a right angle.
There was also a swelling above the crest of the ilium, but no fluctuation
could be detected. There was also an impulse communicated to the gluteal
abscess when the patient coughed or cried.
04
Poore, Disease of the Sacro-iliac Synchondrosis. [Jan.
May 5. As the opening in the gluteal region showed a tendency to
close, a drainage tube was inserted.
I'lth. Fluctuation was to-day felt in the swelling above the crest of the
ilium, and it was opened.
11th. Water injected into the abscess above the crest of the ilium flows
out through that made in the gluteal region, passing within the pelvis.
Dead bone was detected about the sacro-iliac joint.
19£/i. Patient to-day removed from the hospital.
In reading the histories of these two cases, it will be noticed that there
are certain symptoms common to both, and that in other points they differ.
Gradually increasing lameness, pain on pressure over the sacro-iliac syn-
chondrosis of the diseased side, pain on pressure over the trochanter major,
as well as on striking the sole of the foot while the limb is extended, were
symptoms common to both cases. In Case I. pain was complained of in
the thigh, knee, and leg ; while in Case II. the pain was confined to the
parts about the diseased joint. In Case I. there was at no time any
flexion of the thigh on the pelvis; while in Case II. after a time the thigh
became flexed. Case II. was complicated by abscesses, extra- and intra-
pelvic ; while Case I. presented none. In both cases forced flexion and
rotation caused pain ; while any motion, short of being carried to the
extreme, was free and painless.
Looking at these two cases again, it will be noticed that in some points
they resemble disease of the hip-joint : in fact, both patients were sent to
the hospital Cor treatment of disease of that articulation. Pain on pressure
over the trochanter major, as well as on striking the sole of the foot with
the limb in an extended position, pain at the knee, as in Case I., pain on
motion at the hip-joint when the pelvis was not fixed, are commonly
looked upon as almost diagnostic of disease of the hip-joint ; but free and
painless motion at the hip-joint when the pelvis is fixed, as well as the
absence of any swelling or tenderness on pressure below Poupart's liga-
ment in front, or behind the trochanter, are conditions not compatible
with disease of that articulation.
Disease of the sacro-iliac synchondrosis is quite rare. I cannot find a
case reported in the record-books of the New York Hospital; but three
specimens of disease of this joint have ever been presented at the New
York Pathological Societ}r, and but two are recorded in the reports of
the London Pathological Society. Standard works on surgery have but
little to say on this subject ; in fact, in many no mention is made of disease
of this joint, if we except the last edition of Erichsen's Surgery, where a
clinical lecture published in the Lancet in 1869 is reproduced. Hilton,
in his lectures on " Rest and Pain," has treated the subject more thoroughly
than any other English writer. Mr. C. Heath has reported some cases in
the British Medical Journal, January, 1876. In the French medical
literature we find disease of this articulation more frequently mentioned :
the theses of Girauld de Nolhac, in 1840 ; Joyeaux, 1842 ; Boissarie,
1878.]
P o o k e , Disease of the Sacro-iliac Synchondrosis.
60
1862 ; Delens, 1872 ; and Brngel, 1877, as well as the surgical works of
Nelaton, Follin, and Fano should be mentioned.
The two cases occurring in my own practice, together with fifty-six
collected from foreign and domestic medical journals, form the basis of
this paper.
The following table shows the age and sex in the fifty-eight cases in
which they are noted : —
Age. Males. Females.
Under 10 years of age ....... 4 3
Between 10 and 20 years of age ..... 4 3
" 20 " 30 " " ...
" 30 " 40 "
" 40 " 50 "
Adults .
Over 60 years of age
Age and sex not given
9 9
3 4
2 3
7 5
1 0
30 27—58
The youngest was four years of age, the oldest sixty-one. The disease
occurred in 25 cases on the right side, in 24 on the left, in two it was
double, and in 7 the side was not mentioned.
In considering the subject of disease of the sacro-iliac joint, a distinc-
tion should be made between a certain class of cases connected with the
puerperal state, described as simple relaxation of the symphysis, and those
more profound changes due to direct injury, or secondary to inflammation
of the soft parts within the pelvis, although from a careful reading of the
histories of some of the puerperal cases, it would appear that what was
looked upon as a simple relaxation at a former pregnancy, has been fol-
lowed, at a later confinement, by serious changes in the articulation. The
consideration of cases belonging to the latter class would naturally find a
place in a paper of this kind, while those cases of simple relaxation
should be excluded.
Cause — Of the 30 cases occurring among males, in 12 no cause was
assigned, five were due to an injury, one to a strain in lifting a heavy
weight, four to gonorrhoea, one to rheumatism, five were secondary to
Pott's disease, one case followed measles, and was assigned to " cold." In
some of the cases due to gonorrhoea, a subsequent contraction of the dis-
ease was followed by renewed trouble in the sacro-iliac articulation.
Of the 27 cases occurring among females, in 12 no cause was assigned,
11 were connected with the puerperal state, two were due to an injury,
one to a strain from carrying a heavy weight, and one followed continued
fever. Of the 11 cases dependent on parturition, five were subsequent to
a tedious labour, due either to a large child, or a contracted pelvis, in three
pyemic abscesses were found in the joint, one case was secondary to
phlegmasia dolens, one to a uterine phlebitis, one to phlegmonous infiam-
No. CXLIX Jan. 1878. 5
G6 Poore, Disease of the Sacroiliac Synchondrosis. [Jan.
mation of the pelvic fascia. In one case the sacro-iliac joint was injured
during the delivery of a dead child with forceps ; both the patient and
physician t heard a distinct cracking; this was immediately followed by
intense pain and swelling at the left sacro-iliac joint, and later, by both
extra- and intra-pelvic abscesses. In one case there was a history of pain
and difficulty in walking, subsequent to a previous confinement ; this was
aggravated by a second pregnancy, and was followed by displacement of
the ilium on the affected side. Nine of these eleven cases were accom-
panied by abscesses. Martin and others have observed disease of the
sacro-iliac synchondrosis generally after the birth of large children, or in
narrow pelves. (Berl. Klin. Woch., Sept. 27, 1875.)
The course of the disease may be either acute or chronic. Fagan has
reported a case in a child following a fall, and although accompanied by
extra- and intra-pelvic abscess, complete recovery took place at the expira-
tion of seven weeks.
The occupations of the patients is given in 21 cases. Six cases oc-
cured among soldiers, four were labourers, one was a carpenter, one a
tradesman, one a student, one a cook, one a washerwoman, three are
spoken of as " ladies." Hahn has observed three cases among tailors. It
would appear from the above that the disease is more common among the
labouring class.
Symptoms The symptoms of disease of the sacro-iliac synchondrosis
may be studied under the following heads : I. Pain ; II. Lameness ; III.
Swelling ; IY. Abscess ; and Erichsen adds a fifth, alteration in the
shape of the limb.
Pain is constantly present, except, perhaps, in the earliest stage of
the disease, when the patient bears any weight upon the affected side,
or when any motion is communicated to the joint. It may be of two
kinds, (a) pain at, or about, the diseased joint, (b) pain referred to
a distant part, as down the limb of the affected side, (c) or pain may be
complained of in both localities, and, in a few cases, down the limb of the
opposite side.
In Case No. II. the pain was confined to the joint, and was always
present when any weight was borne upon, or motion communicated to it.
When the patient was quiet in bed, he was perfectly comfortable, and
could flex, extend, and rotate the thigh of that side, but standing and
walking were almost impossible on account of the acute pain. In 14 cases
the pain is stated to have been confined to the gluteal region, as " behind
the hip," " at the side of the pelvis," " at the sacro-iliac joint," " about
the hip but not in it." In Case L, recorded in this paper, no pain was
complained of at the affected joint, unless pressure was made directly upon
it, but when standing or walking pain was complained of on the outside of
the thigh, in the knee and leg. In five cases pain was complained of at the
knee and lower portion of the thigh, in two cases in the thigh and leg, in one
1878.] Poore, Disease of the Sacro-iliac Synchondrosis,
07
case intense pain in the calf was all that was complained of, in five cases
in the thigh to the knee-joint. In none of the above cases was there any
pain at the diseased joint unless pressure was made upon it. In five cases
pain extended from the diseased joint down to the knee and leg, in nine
it was at the joint and along the course of the sciatic nerve, in three it
was in the joint and down the anterior or inner aspect of the thigh to the
knee, in one case there was pain in the joint and over the abdomen, and
in one in the joint. Pain in these cases followed the sciatic, obturator,
gluteal, and anterior crural nerves. In those cases where the pain was in
the course of the anterior crural nerve, there existed intra-pelvic abscesses,
and in the case where there was pain over the abdomen, symptoms of
disease of the sacro-iliac joint did not appear until later, although they
were carefully looked for.
Heath, Gueniot, and Mason, have each reported a case where there was
pain in the opposite limb to the one corresponding to the diseased joint.
In each of these cases there existed an intra-pelvic abscess with pressure
on the sacral plexus (at least in one). Boissarie makes mention of the
same symptom.
The pain in sacro-iliac disease is almost always greatly relieved, and
often entirely ceases, when the patient assumes the recumbent position.
Pain is always present, in cases at all advanced, when the patient is
standing, or when any weight is borne by the joint. Gosseiin mentions a
case, due to gonorrhoea, where the pain was worse at night when the
patient was in bed.
Pain was excited by traction in Case I., and Larrey noted the same fact
in one of his patients.
There is an entire absence of those starting pains at night, so character-
istic of hip-joint disease. >
The mode of accession is stated in 32 cases ; in fourteen it was gradual,
and in eighteen sudden. In the former class, vague pains after a fatiguing
walk, a sense of weariness, or weakness in the back, obtuse pain about
the gluteal region, the feeling of a want of support in the lower part of
the body, pain of a rheumatic character, were complained of. In the
latter class, the patient may suddenly be seized with acute pain so as to
be unable to move, or it may come on after a sudden movement in bed,
or immediately after an injury or strain ; in a word, it may resemble, in
its mode of accession, inflammation of any other joint.
Lameness is a constant symptom ; early in the disease it may be slight,
or only appearing after a fatiguing walk or sudden exertion, it soon in-
creases, until, in some cases, locomotion is impossible. The gait is
unsteady ; when the patient is able to walk, the foot is not placed firmly on
the ground. There is not, as a rule, any change in the position of the
foot. In standing, the whole body is thrown over on the sound limb in
order, as much as possible, to relieve the inflamed joint from all pressure,
68
Poore, Disease of the Sacro-iliac Synchondrosis.
[Jan .
giving to the affected side of the pelvis a rounded-out appearance ; this is
often increased by the presence of an abscess under the gluteal muscles.
Tenderness over the sacro-iliac synchondrosis is always present. There
may be a diffuse tenderness on pressure over the whole gluteal region, but
it gradually increases as you approach the joint, where it will be most
marked. In some cases the joint is exquisitely tender, while in others,
quite firm pressure is borne with but little complaint ; comparison with the
sound side will, however, show a difference.
Motion at the hip-joint, on the affected side, is free, smooth, and pain-
less, when the pelvis is fixed, except when carried to extreme flexion and
rotation, provided there is an absence of intra-pelvic abscess. In 29 cases
the state of the joint in this respect is mentioned, and in all these cases it
was good.
In 11 cases the thigh was more or less flexed on the pelvis, and, in a
few, adducted. In Case II., at the time of admission, movements at the
hip-joint were normal, and there was no flexion ; but after a time the
thigh gradually became flexed on the abdomen, and shortly after an intra-
pelvic abscess was discovered. In nine of these eleven cases the presence
of an intra-pelvic abscess is mentioned, and in two no attempt seems to
have been made to decide this point. It would seem highly probable,
from the above, that flexion of the thigh would strongly indicate the
existence of an abscess within the pelvis. The presence of intra-pelvic
abscess is noted in 15 cases, but the position of the thigh is not men-
tioned.
Erichsen, Delens, and others, speak of a change in the apparent length
of the limb on the affected side. Mr. Erichsen makes the following state-
ment : —
" Alterations in the shape of the hips and length of the limb are early,
and marked from the very commencement of the disease ; the limb on the
affected side will seem to be longer than on the sound side, due to a tilting
forwards, and rotation of the pelvis dependent on swelling of the articula-
tion." Heath also mentions this apparent lengthening of the limb as one
of the prominent symptoms, yet in the three cases which form the subject
of his clinical lecture, the state of the limb is mentioned only in one, and
in this he states that " there ivas no change" notwithstanding the fact
that these were of some duration, and accompanied by intra- and extra-
pelvic abscesses.
In the two patients whose history is given in this paper, there was no
change in the length of the limbs. In 15 cases the state of the limb is
mentioned, in seven there was no change, three were apparently length-
ened, and five apparently shortened. Nelaton states that the limb on the
affected side may be apparently lengthened, and that this elongation may
be succeeded by apparent shortening. It would therefore seem that this
change in the length of the limb is not as constant a symptom as some
1878.] Poore, Disease of the Sacroiliac Synchondrosis.
69
writers would lead us to suppose. This change in the apparent length of
the limb, when it does exist, is due to alterations taking place in the liga-
ments, and tissues about the joint, which allow the ilium to be rotated
downwards and forwards, in those cases where lengthening is found, and
upwards and backwards where there is shortening. The distance from
the anterior superior spine of the ilium to the internal malleolus, remains
the same. Halm mentions a case where there was a deviation inwards
and backwards, of the right thigh (the diseased side), so that the right
knee crossed behind the left, the right ilium was displaced inwards, and
the sacro-iliac joint anchylosed. There is no lordosis, nor twisting of the
pelvis, so constant a symptom of disease of the hip-joint.
Martin and Collineau mention two cases of disease of the hip-joint,
complicated with disease of the sacro-iliac synchondrosis of the affected
side. Mr. Holmes seems to look upon it as not an unusual complica-
tion.
Verneuil reports a case where there existed hyperesthesia of the limb
of the diseased side. Gueniot, where both limbs were similarly affected ;
and Hilton, where there was hyperesthesia of the calf. In the first two
cases there were abscesses within the pelvis. Joyeaux mentions a case
where there was paralysis of motion and sensation in the limb of the dis-
eased side, with extensive collection of matter within the pelvis.
Sayre, in his work on "Orthopedic Surgery," page 328, makes the fol-
lowing statement: "While the inflammatory process is going on, the
patient will complain of difficulty in making water, difficulty in having a
movement from the bowels, and more or less pain in the bowels ; in short,
the same class of symptoms referable to the front part of the body of which
the patient complains who has Pott's disease of the spine." The distri-
bution of the nerves irritated is not "to the front of the body," and diffi-
culty in making water and difficulty in having a movement from the
bowels are not mentioned as symptoms of sacro-iliac disease in the 58
cases analyzed, and I can see no anatomical reason for their existence,
except when the bladder or rectum is pressed upon by an abscess.
Pain in the bowels is, however, a prominent symptom of Pott's disease
in the dorsal region, and difficulty in micturition and defecation is asso-
ciated with pressure on the cord.
Abscesses were found in 37 cases; in 16 no mention is made on this
point ; and in 5 none could be found. They may be either extra- or intra-
pelvic ; may be confined to the joint, or may exist in all these localities.
Abscesses, extra-pelvic Of these there were 5 cases : it may be found
over the joint, first as an oblong swelling, not movable on the bone, pain-
ful upon pressure; later the pus may extend under the gluteal muscles
towards the trochanter major, but not reaching it, there is usually a dis-
tinct sulcus between the abscess and that bone. The pus may extend
backwards so as to cover the posterior surface of the sacrum, or downwards.
70 Pooee, Disease of the Sacro-iliac Synchondrosis. [Jan.
In Case II. there were two abscess cavities : one superficial, the other
deep under the gluteal muscles, probably communicating through a small
opening. Gueniot found a similar condition in one of his cases ; and Bois-
sarie, Fano, and Follin refer to the same fact. Muston found a sinus
extending from the groin around the hip-joint on to the dorsum of the
ilium.
In six cases, at post-mortem examination, the joint was found filled
with pus.
Abscesses, intra-pelvic — Of these there were ten cases. The pus may
be between the bone and the iliac fascia ; may be in the psoas muscle ;
may extend backwards so as to cover the anterior face of the sacrum. In
case both joints are diseased, it may occupy both psoas muscles. The ab-
scess may discharge in the groin, per rectum, or vaginam.
Abscesses, both extra and intra-pelvic Of these there were sixteen cases.
They may either communicate through the sacro-sciatic notch, or be dis-
tinct, one passing down behind the iliac fascia, or in the psoas muscle, the
other being beneath the gluteal muscles. In Case II. a distinct impulse
was communicated to the abscess under the gluteal muscles in coughing.
Heath observed the same symptom in one of his patients. W. Morrant
Baker reports a case in which a gluteal abscess, due to disease of the sacro-
iliac articulation, was found to contain blood which came from within the
pelvis through the sacro-sciatic notch ; the hemorrhage was so profuse that
he was compelled to ligate the common iliac. The hemorrhage was sup-
posed to come from a branch of the iliac artery that had ulcerated.
Mustin mentions a case where both lower extremities became enor-
mously oedematous from plugging, first of the iliac vein of the left side, then
of the right. At post-mortem examination the iliac vessels were found to
be firmly imbedded in the walls of a large abscess ; the left vein was filled
by a fibrinous clot which entirely obliterated its cavity, and extended down
the vein on the opposite side.
In two cases dead bone came away through an abscess which discharged
per rectum. Erichsen mentions having met a tympanitic abscess from the
passage of flatus into an abscess discharging per rectum.
In some cases crepitus was detected in the joint.
Pathological Anatomy The articulation between the sacrum and
ilium comes under the class of amphiarthrodial joints. The articulating
surfaces are formed of fibro-cartilage lined by a partial synovial membrane ;
the bones are connected together by external and internal ligaments of
great strength. Changes may be found in all these tissues. Erichsen
found erosion of the cartilage in a case of six weeks' duration ; while in a
case of two years' standing there existed degeneration of the cartilage with
but slight change in the ligaments and bones. Stoll found the ligaments
destroyed, and the articular surface of the bones carious. Hahn found
extensive disease of the bones ; Weisse profound changes in the joints and
1878.]
Poore, Disea.se of the Sacroiliac Synchondrosis.
71
bones. Larrey reports great mobility between the sacrum and ilium, with
entire destruction of the joint, and considerable loss of substance from the
sacrum and ilium. Sequestra were found in the joint by Hamilton, Ver-
neuil, and Gounoud.
The joint may be affected primarily or secondarily.
In 22 cases in which post-mortem examinations were made, 13 seem
to have belonged to the first, and 9 to the second class. Of the latter o
were secondary to disease of the lumbar vertebras; in 3 cases the disease
was subsequent to a phlegmonous inflammation of the pelvic fascia, and in
one case it was due to disease of the ilium.
In three cases metastatic abscesses were found in the joint.
The result is given in 48 cases : 23 were cured, 1 improved, 3 remained
in the same condition as when first seen, and 23 died. Of the latter
10 died from exhaustion, 3 from pyaemia, 1 from erysipelas, 1 from diar-
rhoea, 1 from hemorrhage from the iliac artery, 1 from phthisis, and in 6
no cause is assigned.
Of the 23 who recovered, in 9 there existed abscesses, and in 10 there
was no mention made in regard to them.
Treatment The. purpose of the sacro-iliac joint being to unite and
bind together the bones of the pelvis, so as to form a firm basis of support
for the body above, and for attachment of the lower extremities below,
demands that there should be no motion between the constituent parts of
the joint. A glance at its structure shows how perfectly this is accom-
plished by the strong ligaments within and without the joint. Any relaxa-
tion of this bond of union, not to mention any more profound change in
the articulation, makes locomotion difficult if not almost impossible. The
indications for treatment in disease of this joint are to aid nature in ob-
taining immobility between the bones forming its boundary. Post-mortem
examination of those who had profound disease of this articulation, and who
have recovered, shows the bones firmly united together, and all treatment
should tend to aid nature in establishing anchylosis. In every case where
the treatment is mentioned, it consisted of absolute rest in bed during the
more acute stage of the disease. Later, in many cases firm support by
some kind of a bandage around the pelvis so as to prevent all movement
between the sacrum and ilium. Heath speaks highly of a bandage consist-
ing of two pieces of strong inelastic webbing, starting from either side of a
wooden pad placed over the symphysis pubis, one passing to the right,
the other to the left, crossing behind, and after surrounding the pelvis,
secured again to the pad; this should be drawn as tightly as possible.
With some support of this kind patients are able to go about without any
inconvenience, while without it locomotion is difficult. Sayre advocates
extension by raising the sole of the shoe on the sound side so as to allow
the limb on the affected side to swing, making use of it as an extending
force. In Case I. extension was tried, but it had to be removed on account
72 Poore, Disease of the Sacroiliac Synchondrosis. [Jan.
of the great pain it caused. The exquisite pain caused by traction on in-
flammed tissues in and about the joint, would make this mode of treatment
impossible in many cases. Extension in disease of the hip-joint is not to
separate the head of the bone from the acetabulum, but to control muscular
spasm. The joint under consideration is not acted on directly by muscles
as the hip-joint is, and therefore the extension would not be indicated.
Ten cases were cured by absolute rest in bed, and later by some kind of a
pelvic band; eleven by simple rest; one by rest and a long splint; one
by the continuous application of ice for three weeks.
In some cases the use of the actual cautery was beneficial. Tonics and
good nourishment are called for in all cases of joint disease. Those cases
complicated by abscesses seem to have done best when the pus was early
evacuated. In cases reported recently the frequent use of the aspirator
seems to have been attended with good result; but, whether free incision
or the aspirator is used, the abscess cavity should be kept free from pus.
The question of attempting to remove dead bone, when it can be detected,
is viewed differently by different surgeons. Mr. Erichsen states that no
operation is admissible. Mr. Bryant states that he has taken a large
piece of bone from this joint in a young girl with great benefit, and Sayre
says that he has operated often with good result. The fact, that opera-
tions for the removal of diseased bone have been performed with benefit,
would seem to indicate that they should not be condemned as strongly
as they are by Mr. Erichsen. Personally, I have had no experience in
operating, but would certainly make the attempt to remove diseased
bone when I could satisfy myself of its presence, and I do not see how
such a procedure could add to the gravity of the disease.
Diagnosis Sacro-iliac disease is most frequently mistaken for hip-joint
disease. The diagnosis from the latter may be made by attention to the
following points : The pain from sacro-iliac disease is behind the hip-joint,
or is referred to the thigh, knee, or leg ; when the pain is in the knee,
the absence of other symptoms of hip disease should direct our attention
elsewhere. In the early stage of sacro-iliac disease, and until the
formation of intra-pelvic abscesses, in those cases complicated by them,
there is no flexion of the thigh on the pelvis and no lordosis, while
in hip disease these are early and constant symptoms. Motion at the
hip-joint in sacro-iliac disease is perfectly smooth, free, and painless, when
the pelvis is fixed; in hip-joint disease it is always limited, and, in cases at
all advanced, ahvays painful. In sacro-iliac disease the pelvis does not
move with the thigh ; in hip-joint disease it does. In sacro-iliac disease
there is no pain on pressure, either below Poupart's ligament in front, or
behind the trochanter major; in hip-joint disease this is a marked symptom.
Pressure on the ilium, at right angles to body, or attempting to rotate this
bone, always causes pain in sacro-iliac disease ; in hip-joint disease it does not.
In sacro-iliac disease there is always tenderness on pressure over the joint;
1878.] Poo re, Disease of the Sacro-iliac Synchondrosis. 73
in uncomplicated hip-joint disease there is none. In hip-joint disease of any
duration there are always sudden attacks of pain at night ; in sacro-iliac
disease they are absent. There is no absolute shortening of the limb on the
affected side in sacro-iliac disease ; in tjie more advanced stage of hip-joint
disease there is. Intra-pelvic abscesses may be an early accompaniment of
sacro-iliac disease; they are only found late in hip-joint disease. Extra-
pelvic abscesses in sacro-iliac disease are behind the hip-joint, and there is
usually a distinct sulcus between the abscess and the trochanter ; in hip-
joint disease the pus is found either about the joint, or in the thigh, and
there is thickening of the tissues about the joint. The attitude assumed
by the patient, when standing, in sacro-iliac differs from that in hip-joint
disease ; in the former the body is thrown on to the sound side, so as to
relieve the inflamed joint from all pressure, while in the latter the thigh is
flexed, and the pelvis twisted. Locomotion is more painful in sacro-iliac
than in hip-joint disease, and greater relief is experienced from absolute
rest in bed in the former, than in the latter disease.
Bibliography. — 31. Velpeau, Gaz. des Hopit. 1862, p. 105. — Boissarie, de la Sacro-
eoxalgie, Thdse de Paris, 1862. — Arch. Gen. de Med. t. iv., 1834, p. 657, review of Hahn's^-
work.— Xelaton, Pathologic Chir. vol. ii. p. 217.— Brodie's Works, vol. ii. p. 376.— Hil-
ton, Rest and Pain, p. 407, etc.—Erichsen, Lancet, 1859, vol. i. p. 25.—Hitlke, Trans.
London Path. Soc. vol. xiv. p. 208. — Esmarch, Cold in Surgery, Selected Monograph
New Sydenham Soc. 1861, p. 309. — Hamilton, Med. Record, vol. ii. p. 88. — Morris, Med.
Times' and Gaz. 1873, vol. ii. p. 354. — Mason, Med. Record, 1875, p. 860. — Baker, St.
Barth. Hosp. Rep. vol. viii. p. 120.— C. Heath, Brjt. Med. Journ. 1876, vol. ii. p. 781.—
Faqan, Lancet, 1875, vol. ii. p. 49. — Mustin, Trans. Path. Soc. of Phil. vol. iii. p. 139. —
King, Am. Journ. of Obstet. vol. iv. p. 402.— Ebell, Zeitschr. f. Gehurtsh. vol. i. 1876,
p. 619 ; Berl. Klin. Woch. Sept. 27, 1875. — Fruitnight, Am. Journ. Obstet. vol. ix. p.
mo.—FoUin, Path. Extern, vol. iii. p. 98.— Hakes, Med. Times and Gaz. 1862, vol. i. p.
412. — Sayre, Orthopedic Surgery, p. 332.—Jewctt, Maine Med. Assoc. Rep. 1869-70, p.
128. — Nouveau Diet, de Med. et de Chirurg. Pratiques, Paris, 1866, Art. Bassin, p. 639,
etc. — Kichet, Gaz. Med. de Paris, 1840, p. 443, obs. XY.— Girauld de Nolhac, These de
Paris, l$±0.—Joyea%ix, These de Paris, 1842.— Stoll, Schmidt Jahr. t. Iii. p. 81, 1844.—
Rollet, Gaz. Med. de Lyons, 1858. — Verneuil, Bull, de la Soc. Anat. Paris, 1865. — Gos-
selin, Gaz. des Hopit. 1868, p. 574.— Gosselin, Gaz. des Hopit. 1870, p. 297. — Delens,
These pour 1. agregation, 1872. — Martin, M. F., Bull, de Therapeutique, vol. 40, p. 10S,
puerperal. — Putegat, Bull, de Therapeutique, vol. 43, p. 322, puerperal. — Futegat, Bull,
de Therapeutique, vol. 64, p. 123. — Debout, Bull, de Therapeutique, vol. 64, p. 20. —
Courot, Bull, de Therapeutique, vol. 64, p. 37. — Stoltz, Bull, de Therapeutique, vol.
64, p. 354. — Jocquier, Bull, de Therapeutique, vol. 55, p. 121. — Frichsen, Surgery, Phila.
1873, vol. ii. p. 276. — Holmes, System of Surgery, 1st ed. vol. iii. p. 785. — Gxieniot,
Bull, de la Soc. Anat. 1861, p. 98. — E. Martin et Collineau, de la Coxalgie, p. 400. —
Brugel, These de Paris, 1877.— Satterthwaite, Med. Record, May 26, 1877, p. 327.— Boyer,
Traite des Mai. Chir. vol. ii. p. 243.— Larrey, Clinique Chirurg. 1829, t. iii. p. 330.—
Diet. Encvclop. des Science Med., article Sacro-iliaque. — M. Ledentu, Bull. Mem. Soc.
de Chir., Paris, t. iii. No. 2, 1877.
The following additional references are given by Delens : —
Louis, de l'Ecartement des os du bassin ; Mem. de PAcad. de Chirg. t. x. ed. Didot.
— Enaux, Nouveaux Mem. de PAcad. de Dijon, ii. p. 152, 1784. — Thomassin, Journ.
de Med. Militaire, 1788. — Lheritier, Journ. de Foucroy, t. iv. p. 236, 1792. — Bust,
Arthrokalogie, Vienna, 1817. — Frere, These de Paris, 1838. — Belineau, These de Paris,
1842. — Maisonneuve, de la Coxalgie, These d'Agregation, 1844. — Lenoir, Mem. lu. a.
PAcad. de Med. le ler anne 1851. — Hattute, These de Paris, 1852. — Crocq, Traite des
tumeurs blanches ; Bruxelles, 1853, p. 451. — Gurlt, Beitraege zur vergleichenden patho-
logischen, der Gelenkkrankheiten, Berlin, 1853. — L. Labbe, de la Coxalgie, These
d'Agregation, 1863.— Bolbeau, Clinique Chir. 1867, p. 390.— S. Buplay, Traite de Patho-
logie, iii. p. 98, 1868. — Lusclika, Praktische Anatomie des Menschen, ii. Bd. 2 Abth.
Emmert, Lehrbuch der speciellen Chir. 1871, 2 Bd. p. 192.
74 Cutler, Bradford, Globular Richness of the Blood. [Jan.
Article IV.
Action of Iron, Cod-liver Oil, and Arsenic on the Globular Rich-
ness of the Blood. By Elbridge G. Cutler, M.D., and Edward H.
Bradford, M.D., of Boston.
It is very generally believed that iron is of great benefit in anaemia.
The action of the drug is, however, a subject of discussion, and may be
said to be little understood.
Trousseau says that iron supplies in chlorosis the principal element
which is wanting, but he is uncertain whether the drug acts chemically or
merely as a tonic, he is inclined to believe that it has a double action.1
Headland2 does not regard iron as a true tonic, as, in simple debility,
unless there be anemia present the drug is of no service. Bouchardat3
and Wood* seem to regard the action of iron as chemical. Fleury5 states
that iron increases the number of the red corpuscles. Nothnagel states
that this is probable, but not as yet proved.6 Andral,7 Simon,8 and Head-
land report cases in which the red corpuscles were observed to increase in
number under the use of iron. Hayem9 investigated the action of iron in
anaemia, making use of his modification of the apparatus for counting the
corpuscles devised by M. Malassez,10 and finds that the action of iron in the
curable forms of anaemia is more in increasing the colouring power of the
corpuscles than their number.
M. Malassez himself, we believe, has made no observations with regard
•to the action of iron on the blood corpuscles, although his investigations
as to other changes in the number of the corpuscles have been very care-
ful and thorough. Malassez's method of counting blood corpuscles and
M. Hayem's modification are both so well known that no description is
necessary. The accuracy of these methods has been abundantly demon-
strated.
The following are the results of a few observations made as to the action
of iron upon the number of corpuscles of the blood. They were made
with great care, the method of M. Malassez being employed.
A. Action of Iron on Healthy Subjects.
Case I. — Healthy male, aged 30 years. Globular richness — i. e. number of
globules found in the cubic millimetre — of blood from prick in the finger.
1 Trousseau, Traite de Therapeutique ; article Fer.
3 Action of Medicines, 4th ed. pp. 164 and 166.
3 Manuel de Matiere Medicale, 3me edition.
* Tkefap. Mat. Med. and Toxic, Phila., 1871, p. 77.
5 Lecons de Therapeutique.
6 Handbuch der Arzneimittellehre, Berlin, 1874.
7 Quoted by Waring, Pract. Therap., 2d Amer. ed., p. 265. 8 Ibid.
s Gaz. Hebd., Dec. 1, 1876, and in subsequent articles.
10 Described in the Archives of Phys., 1873.
1878.] Cutler, Bradford, Globular Richness of the Blood. 75
Red corpuscles . . . .3,663,309
White " ..... 4,577
Ratio of white to red . . 1 to 800
Ferrum redactum (.25 gramme) was taken three times a day for eight days,
and the blood again counted. ;
Globular richness, red .... 3,588,100
" " white . 4,942
Ratio 1 to 725
Tinct. ferri chloridi, 1.23 c. c. (ui xx), was then given ter in die for a week,
when examination showed —
Red corpuscles . . . . . 3,439,160
White " ... . . 4,062
Ratio 1 to 937
Rabuteau's Dragees of the protochloride of iron (25 milligrammes) were then
given three times a day for a week, when the count gave —
Red corpuscles 3,617,888
White " 4,062
Ratio 1 to 890.
No particular effect of iron was noticed, except blackening of the fasces.
The iron was then discontinued, and six days later it was found that the
Red corpuscles numbered . . . 3,804,700
White " " ... 4,062
Ratio . . . . 1 to 936
There was, therefore, in this case no increase of the red corpuscles
while iron was given ; there was a slight decrease under ferrum redactum
and tinct. ferri chloridi (224,000 in two weeks), and a rise while the pro-
tochloride of iron was used (178,000 in one week). The increase in the
globular richness after discontinuing the iron was marked (nearly 200,000
in one week). The white corpuscles remained about the same throughout.
Case II. — Healthy adult male (30 years). Globular richness of blood from
finger was —
Red corpuscles . . . . . 4,400,000
White not recorded.
Ferrum redactum (26 milligrammes) was taken three times a day for one week.
Red corpuscles then numbered . . 4,390,140
White " " " . . 4,785
Ratio 1 to 917
Tinct. ferri chloridi, 1.23 c. c, taken three times a day, gave in a week a count
of—
Red corpuscles . . . . . 4,115,100
White " 5,075
Ratio . . . . . 1 to 810
Rabuteau's Dragees of the protochloride of iron (25 milligrammes), three times
a day, gave in one week a globular richness of —
Red corpuscles ..... 4,046,950
White " . . . . . 4,292
Ratio . . . . . 1 to 942
No more iron was taken for a week, and the count then showed —
Red corpuscles ..... 4,087,550
White " 7,975
Ratio 1 to 512
In this case, also, there wTas no increase while iron was taken ; there
was a decrease during the administration of tinct. ferri chloridi, and also
70 C utler, Bradford, Globular Richness of the Blood. [Jan.
of the protochloride of iron (340,000 in two weeks). There was no
marked increase after the cessation of the iron.
The only conclusion from these two cases is, that no increase in the
globular richness can be attributed to the use of iron. The variations
which occurred were not constant in both cases, and were not greater than
the variations from week to week, which we have observed to occur phy-
siologically.1
It cannot, therefore, be inferred that the drug had any effect upon the
number of the corpuscles ; it is certain that there was no marked effect.
B. Action of Iron on Unhealthy Subjects.
Iron given to a system in a pathological state may be supposed to act
differently. The following are the results of our investigations in cases of
anemia. The examinations were all made at the same time of day, and
though the patients (taken from an out-door clinic) were not under com-
plete supervision, inquiries were carefully made, and as far as possible any
change in occupation was ascertained. In all cases where we considered
there was any doubt as to the administration of the drug, or where there
was a probability of other causes than the medicine affecting a change in
the condition of the patient, the cases were not reported. The examina-
tions were made in each case by the same observer, using the same instru-
ments.
Case I. — Female, aged 23, servant ; has had in the last seven years a few
attacks, perhaps epileptic, perhaps hysterical; has worked hard; an kt attack" a
few clays previous ; complains of debility, headache ; was some time ago obliged
from a loss of strength to leave off work. Menses regular. Quite pale, no ema-
ciation.
Globular richness, blood from finger.
Red . . ' . . . . 2,204,308
White 3,046
Ratio 1 to 723
Tinct. ferri chloridi (.61 c. c. three times a day) was given. Seven days later
(medicine reported as well borne) an examination of blood showed —
Red corpuscles 2,708,000
White " . . . . . 4,400
Ratio . . . . . 1 to 615
Medicine continued. One week later the count gave a globular richness
Of the red 2,935,472
White not counted.
Patient feels improved and is anxious to resume work. Did not appear again.
There was an increase of 731,164 red corpuscles in two weeks.
Case II. — Girl 17 years old. Bellows murmur at the base of the neck; no
heart murmur ; occasional weakness and dizziness.
1 The variations observed may also include errors incident to this method of enu-
meration. The limit of error has been calculated by M. Malassez to be 30,000 red cor-
puscles in a cubic millimetre of blood. By repeated successive examination of the
same blood with the same instrument, we have satisfied ourselves that the limit of error
does not exceed and is probably less than this number.
1878.] Cttiee, Beadfoed, Globular Richness of the Blood. 77
Bed corpuscles numbered . . . 1,929,660
White " " ... 2,900
Ratio ... . . 1 to 665
The red corpuscles were pale, and averaged 6p in diameter.
Tinct. ferri chloridi, .61 c. c. (Tit x), was given three times a day for a week.
Patient had then a little more colour in fac^e, and reports feeling a little better.
Red corpuscles found to number . . 2,227,200
White not accurately counted.
An increase of 1,021,960 red corpuscles occurred in two weeks.
Case III. — Girl 16 years old. Pallor, poor appetite, loud bruit de diable in
neck on both sides, none over heart, menses regular. The
Eed corpuscles numbered . . . 2,389,600
White " " ... 2,900
Ratio . . . . . 1 to 824
The corpuscles were very pale; the greater number 5/x in diameter, a few 10 /x.
Tinct. ferri chloridi, .61 c. c, given three times a day for a week. Patient then
reported herself feeling better, more colour in face. Examination of the blood
then showed —
Red corpuscles 2,885,500
White not counted.
Tinct. ferri chloridi continued in the same quantity, and in eight days the
patient again presented herself, having been out of medicine for one day. The
count showed —
Red corpuscles ..... 2,587,500
White not taken.
Red corpuscles were small, averaging op in diameter. An increase of 147,900
occurred, therefore, in two weeks.
Case IV. — Girl 1 7 years old, very pale, no colour in lips or conjunctivae, loud
bellows murmur over aortic and pulmonic valves, pain in left side, menstrual flow
diminished. Examination of the blood showed —
Red corpuscles . . . .'. 2,172,100
White " . . . . • . 2,900
Ratio . . . . . 1 to 749
Red corpuscles quite small.
Tinct. ferri chloridi ordered, .92 c. c. four times a day.
Presented herself a fortnight later, had had a severe cold for a week in the
mean time. Symptoms otherwise about the same.
Red corpuscles . . . . . 2,554,900
White " 8,700
Ratio 1 to 293
Patient seen a month later, had left off medicine, as she felt well enough. Blood
not examined.
An increase of 382,800 red corpuscles occurred in this case in two weeks.
Case V. — Girl aged 20 ; claims to have, been always delicate ; figure slight,
quite pale ; complains of loss of appetite and strength, but is able to work. Had
typhoid fever a few months previous, but made a good recovery. At work as a
compositor.
Red corpuscles found to number . . 1,408,160
White not counted.
Tinct. ferri chloridi, .61 c. c, given three times a day. Patient to remain at
work. A week later patient reported.
Red corpuscles numbered . . . 2,932,764
White " " ... 4,739
Ratio 1 to 618
There had been an increase of 1,524,604 red corpuscles in one week.
78 Cutler, Bradford, Globular Richness of the Blood. [Jan.
Case VI. — Girl 18 years old ; rather pale, no particular symptoms ; box maker
by occupation. Examination of blood (at 11 A. M.) showed a globular richness of
Red corpuscles 2,453,448
White " ..... 6,41G
Ratio . . . . . 1 to 332
Tinct. ferri chloridi, .Gl c. c, given three times a day. One week later, at 5
P. M. (meal having been taken at noon), an examination of the blood showed —
Red corpuscles 2,560,000
White not counted.
As the second count was made in the afternoon, after a day's work and during
fasting, at a time when it has been proved there is a decrease in the number of the
globules, it is probable that the globular richness at 5 P. M. was lower than at 1 1
A. M. The actual increase in the number of the red corpuscles was 106,552 in
one week. If the second count had been made at 11 A. M., it is probable that a
greater increase would have been observed.
Case VII. — Woman 88 years old ; weak, with a poor appetite.
The red corpuscles numbered . . 2,499,800
" white " " . 5,075
Ratio . . . . 1 to 492
Tinct. ferri chloridi, .61 c. c, given three times a day. One week later
patient considered herself improved, appearance the same, suffered in the past
live days from subacute bronchitis, with muco-purulent expectoration. The blood
count showed —
The red corpuscles .... 3,085,600
" white " .... 10,512
Ratio 1 to 293
Case VIII.1 — Woman aged 26 ; pallor, complained of general debility. Blood
taken from the finger counted.
Globular richness, red corpuscles . . 2,37 7,624
" " white " . . 4,066
Ratio 1 to 584
Tinct. fern chloridi, .61 c. c, was given ter in die. Thirteen days afterwards
the count gave —
Red corpuscles 2,683,628
White not counted.
The above cases were not selected ones, but show the effect of iron on
all the cases of anosmia under observation. In no case did the number of
the red corpuscles diminish or remain the same.
The effect of iron in ancemia is well shown in a case mentioned in the Gazette
des Hdjritaux, Jan. 26, 1876. On the day of entrance, Dec. 4, the patient's
blood showed —
Red corpuscles ..... 2,919,000
Rabuteau's Dragees of the protoxide of iron, two daily (containing 25 milli-
grames), were taken.
Dec. 7, the red corpuscles numbered . 3,486,000
" 12, " " " . 3,696,000
" 24, " " " . 4,578,000
There had been an increase of 1,659,000 red corpuscles in twenty days, or
82,950 a day.
1 Though in this case there was an increase in the number of the corpuscles, during
thirteen days of treatment, the evidence as to the effect of iron is not so strong, as the
patient discontinued work for four days, and the diminution of the anaemia may be
due to this.
1878.] Cutler, Bradford, Globular Richness of the Blood. 7 9
The conclusion to be drawn from these observations is that — ■
In health iron causes no increase in the number of the red corpuscles ;
but in the pathological state called aneemia there is an increase in the
number of the red corpuscles under its use.
Cod-liver Oil. — Messrs. Thompson and Campbell (Schmidt'' 's Jahrbucher,
1855, vol. 85, p. 8) found an increase of the red corpuscles after treatment
with cod-liver oil and oil of coca. Olive oil and oil of sweet almonds did
not bring about the same results.
We have attempted to verify these results by examining the blood of
a healthy person who took cod-liver oil, and also the blood of persons in
impaired health who made use of the medicine.
A. Action of Cod-liver Oil on Healthy Subjects.
Case I. — Male adult. Blood from finger showed before exhibition of the oil
a globular richness of — ■
Red corpuscles 3,317,600
White " . . . . . 3,987
Ratio ... 1 white to 837 red.
Oleum morrhua?, 7.50 c. c, given three times a day. A fortnight later an
examination showed —
Red corpuscles 3,888,900
White " 4,168
Ratio ... 1 white to 932 red.
The oil was continued, and a week later it was found that the —
Red corpuscles were .... 4,466,000
White " " 4,350
Ratio - 1 to 1,026
The oil was discontinued. There had been a steady increase of the red cor-
puscles, and a slight increase of the white in three weeks, amounting to 1,148,400
red corpuscles, and 363 white. The increase in the red was proportionally greater
than in the white, as the different ratios show.
Eight days after ceasing the use of the cod-liver oil, the blood of the same indi-
vidual had a globular richness of —
Red corpuscles . . . . . 3,435,000
White " 4,800
Ratio 1 to 715
That is a marked decrease of the red.
Cod-liver oil was then resumed the next day (18.5 c. c. ter in die). At the end
of ten days an examination showed —
Red corpuscles . . . . . 4,219,500
White " 6,452
Ratio . . . . . 1 to 653
Five days later, the oil having been continued, an examination showed a con-
tinued increase in the globular richness.
The red corpuscles were . . . 4,439,900
" white " ... 6,525
Ratio 1 to 680
There had been in a fortnight again an increase of over 1,000,000 red corpus-
cles in the cubic millimeter of blood, and of over 1500 white.
The oil was discontinued. An examination three weeks later showed a marked
decrease of the corpuscles.
80 Cutler, Bradford, Globular Richness of the Blood. [Jan.
Red corpuscles 3,607,600
White " 2,537
Ratio 1 to 1,027
These figures show satisfactorily that in this case there was an increase in the
globular richness under the exhibition of oleum morrhua?.
B. Action of Cod-liver Oil on Persons not in Health.
Case I. — Girl 21 years old, tailoress. Extreme pallor, cough, asthenia, amenor-
rhoea, night sweats. Physical signs not marked. Rude respiration at apex of ri<rht
lung, no rales.
Red corpuscles 2,031,896
White " • 4,400
Ratio 1 to 462
Cod-liver oil and whiskey (3.70 c. c. each) three times a day were given for ten
days. They were tolerably well borne. Then the count was —
Red corpuscles 2,328,880
White " 4,385
Ratio 1 to 533
Whiskey omitted. Oil continued alone for a week in amount of 7.40 c. c. ter
in die. The count then was —
Red corpuscles 2,098,700
White " 6,431
Ratio 1 to 326
The oil caused some nausea, and the dose was diminished to 3.70 c. c. ter in
die. A fortnight later the count was —
Red corpuscles 2,448,032
White " 10,864
Ratio 1 to 226
The patient felt no better ; the appearance had not improved. A week later
she was confined to her bed.
There had not been a progressive increase of the globular richness under the use
of the oil. There had, however, been an increase during the month of 400,000
red, and 6000 white corpuscles. It is, of course, impossible to state whether in
this case the increase was due directly to the cod-liver oil or to the abatement of
some pathological process which occurred during the time.
Case II. — Girl 18 years old. Early stage of catarrhal pneumonia — bronchial
respiration at the right apex — bronchial expiration at left apex. Pallor, emacia-
tion, cough. No night sweats.
The red cor puscles were . . . 2,572,600
" white " " ... 4,332
Ratio 1 to 593
01. morrhua?, 7.40 c. c. ter in die, given for a week, then diminished to 3. 70 c. c.
ter in die, as it was not well borne. At the end of another week (i. e. a fortnight
after the first use of the medicine) an examination showed —
The red corpuscles to be . . . 2,312,632
" white " " ... 3,385
Ratio . . . . 1 to 683
The oil was continued, and a week later the count showed —
The red corpuscles to be . . . 2,019,776
" white " " . 2,708
Ratio . . . . . 1 to 745
A continued decrease during the use of the cod-liver oil of 500,000 red corpus-
cles and nearly 2000 white in the course of three weeks. There had been no
apparent increase in the severity of the symptoms, but the medicine was not well
borne.
1878.] Cutler, Bradford, Globular Richness of the Blood. 81
Case III. — Girl between 20 and 25 years old ; pale, weak, slight cough. The
blood count showed —
Red corpuscles 3,204,500
White " 2,175
Ratio . . %* . 1 to 1,473
Oleum morrhuas, 7.35 c. c, given ter in die for a week, when the patient reports
herself as feeling somewhat better ; slight improvement in appearance, cough nearly
gone. The blood count showed —
Red corpuscles 3,735,200
White " . . . . . 5,800
Ratio 1 to 642
An increase of 500,000 red corpuscles and 3000 white in a week under the use
of the medicine.
Case IV. — Girl 19 years old. Slender figure. Slight cough, weakness. An
examination of the blood showed a globular richness of —
Red corpuscles 2,406,606
White " 5,416
Ratio . . . . . 1 to 444
Oleum morrhuae, 3.70 c. c, given ter in die. Medicine tolerably well borne.
An examination one week later showed the
Red corpuscles to be .... 2,492,326
White corpuscles not taken.
An increase therefore of 85,720.
Conclusions In the healthy subject cod-liver oil caused an increase in
the number of the red corpuscles and a slight increase in the white.
In certain pathological conditions this seems to be also the case if the
medicine is well borne. If, however, the morbid process is active, and
the appetite is disturbed, the medicine does not appear to check the con-
sequent anasmia.
The following observations show the result of our investigations of the
effect of Fowler's Solution upon the blood.
A. Action of Liquor Potassce Arsenitis on Healthy Subjects.
Case I. — The blood from the finger of an adult male had a globular richness of
Red corpuscles 3,978,800
White " 4,712
Ratio 1 to 844
Liq. potass, arsenitis, .30 c. c, was taken ter in die for a fortnight; the blood
then showed a globular richness of —
Red corpuscles 3,462,600
White " ..... 3,443
Ratio 1 to 1,000
The medicine was continued, and a week later an examination of the blood
showed —
Red corpuscles 3,183,040
White " 1,377
Ratio 1 to 2,310
A week later, the medicine being taken still, the count was —
Red corpuscles 2,888,400
White " 1,087
Ratio 1 to 2,800
No. CXLIX Jan. 1878. 6
82 Cutler, Bradford, Globular Richness of the Blood. [Jan.
The arsenic was discontinued ; it had caused a metallic taste and slight disturb-
ance of digestion.
After a week the blood was examined again, the count showed an increase of
the red corpuscles as follows : —
Red corpuscles 3,242,200
White not recorded.
A week later (the medicine not being taken) the count was —
Red corpuscles 3,219,000
White " 2,170
Ratio 1 to 1,483
And after another week —
Red corpuscles 4,028,100
White " 5,437
Ratio 1 to 740
There was, therefore, in four weeks, during the administration of arsenic, a
diminution of 1,090,200 red corpuscles and 3625 white corpuscles in the cubic
millimeter of blood. The diminution in the white was proportionately greater than
that of the red. In the three weeks when the arsenic was discontinued, there was
an increase in the number of the corpuscles over 1,000,000 red and 4000 white.
At the end of this time the arsenic was again given in the same way, and ten
days later the blood was examined again. The count was —
Red corpuscles 3,891,800
White " 2,537
Ratio 1 to 1,534
Four days later (the drug being continued) the count was —
Red corpuscles ..... 2,872,740
White " 1,087
Ratio 1 to 2, 734
A decrease of over 1,000,000 red corpuscles and of 4000 white, the decrease
of the white being greater in proportion than that of the red.
Case II. — Healthy male adult. Blood from finger gave a globular richness of —
Red corpuscles 3,696,400
White 14 . . . . . 4,365
Ratio 1 to 859
Liq. potassse arsenitis, .30 c. c, was given ter in die, causing at first metallic taste
and slight gastric disturbance. In nine days the count was —
Red corpuscles 3,485,196
White " 1,354
Ratio 1 to 2,570
Five days later the count was —
Red corpuscles 3,303,706
White " 3,046
Ratio 1 to 1,190
Eight days later —
Red corpuscles 2,962,552
White " 2,708
Ratio l to 1,090
Arsenic was discontinued Eight days later the count was —
Red corpuscles 2,967,968
White " 4,739
Ratio 1 to 626
Twenty days later the count was —
Red corpuscles 3,241,476
White " / 6,193
Ratio 1 to 523
1878.] Cutler, Bradford, Globular Richness of the Blood. 83
Twelve days later the count was —
Red corpuscles 3,374,168
White " 3,723
Ratio 1 to 900
Liquor potassae arsenitis, .61 c. c, was „ then' taken again ter in die, and nine
days later the count showed —
Red corpuscles 2,710,708
White " 3,375
Ratio . . . . . 1 to 803
The medicine was stopped. A month after it was discontinued, the
Red corpuscles were .... 3,311,984
White " " .... 4,737
Ratio 1 to 6'90
In this case also there was a marked decrease of the corpuscles, both
red and white, under the use of arsenic (733,848 red, 1G00 white in
twenty-two days), followed by an increase after the drug wTas stopped
(400,000 red corpuscles, and 2000 white in five weeks) ; and a second
decrease when the medicine was again used (600,000 red in nine days.
The decrease in the white was slight), and again an increase after the
medicine was discontinued.
B. Action of Liquor Potassce Arsenitis on Unhealthy Subjects.
Case I. — Girl, 16 years 5 months old; anaemic murmur in the veins of the neck,
cephalalgia, fair appetite, no menstrual disturbance ; weak. The count gave —
Red corpuscles 2,668,000
White " 4,350
Ratio 1 to 613
Liquor potassae arsenitis was given, .30 c. c. ter in die. A week later the patient
presented the same symptoms. The count gave —
Red corpuscles . . . . . 3,140,700
White '.' 10,440
Ratio . . . . . 1 to 300
The patient did not reappear. There had been an increase of 500,000 red
corpuscles in the cubic millimeter of blood, and of 6000 white. The reverse of
what was seen in the previous healthy subjects.
Case II. — A man 32 years old; cabinet maker; for several months had been
very anaemic with no assignable cause. Lately had suffered pain in the cardiac
region, also across the abdomen and in the right hypochondrium. The liver and
spleen were of normal size, there was nothing abnormal detected in the urine, the
retinae on ophthalmoscopic examination were simply pale, there was an anaemic
heart murmur at the base ; appetite and digestion fair, bowels regular. There
was great pallor, conjunctivae had a faint yellowish tinge, the prolabia were exces-
sively pale, nearly colourless. There was dyspnoea on exertion, and disinclination
to take exercise. He could not work. The blood count gave —
Red corpuscles 870,000
White " 2,392
Ratio 1 to 363
The patient was given small doses of iron rather irregularly for a fortnight; the
symptoms remaining the same, no change in the appearance. He then received
for four days .60 c. c. of liquor potassae arsenitis. The count at this time gave —
Red corpuscles . . . . 1,249,900
White " 1,450
Ratio 1. to 862
84 Cutler, Bradford, Globular Richness of the Blood. [Jan.
Ag this dose had caused diarrhoea and some gastric disturbance, it was diminished
to .30 c. c. ter in die. One week later the blood was again examined ; in the mean
time the diarrhoea had ceased, considerable colour had returned to the lips, and
he expressed himself as feeling very well, and was inclined to take exercise, and
commenced talking of resuming work.
Red corpuscles ..... 1,754,500
White " 2,900
Ratio 1 to 605
In eighteen days of mixed treatment there had been an increase of the red
corpuscles amounting to 379,900, the white on the contrary had diminished 942 in
number. During the week that liquor potass, arsenitis was given alone, and so
as not to disturb the bowels and stomach, there was an increase of over 500,000 in
the number of the red corpuscles and an increase of the white amounting to 1450.
Case III. — Man 27 years old. Leucocythaemia. The case has been under
observation for two years, and has been reported up to March, 1877, by Dr. 1\ G.
Morrill in the Boston Med. and Surf/. Journal. Through the kindness of Drs.
Lyman, Edes and Draper of the Boston City Hospital, where the patient has been
since April, 1877, the arsenic treatment has been adopted, and we have been
allowed to examine the blood. The count gave —
Red corpuscles 3,064,080
White " 1,073,040
Ratio 1 to 2.85
For seven weeks he received .30 c. c. liq. potassae arsenitis ter in die, for the
next three weeks it was increased to .60 c. c. ter in die, when the count was —
Red corpuscles 2,334,500
White " 60,175
Ratio 1 to 38.+
The medicine was continued two and a half weeks longer, when the count was —
Red corpuscles ..... 1,841,500
White " 8,700
Ratio 1 to 211
As the drug was causing disturbance, it was omitted, and iron substituted in dose
of .30 c. c. ter in die. Three weeks later the count was —
Red corpuscles 3,375,600
White " 19,937
Ratio 1 to 169
The iron was omitted and potassii iodidum substituted. Four weeks later the
count was —
Red corpuscles 2,543,300
White " ... . 621,325
Ratio 1 to 4.+
Liquor potassae arsenitis, .30 c. c. ter in die, was then given in addition, and five
weeks later the count was —
Red corpuscles 3,143,600
White " 84,187
Ratio 1 to 37. -H
Conclusions Liquor potassae arsenitis given in health caused a pro-
gressive decrease in the number of the red and white corpuscles, that of
the latter being most marked.
In simple anaemia, on the contrary, there seems to be an increase at first
of both the red and white corpuscles. After a certain point there is a
steady diminution of both, however.
In the case of leucocythemia there was a decrease in both the red and
white corpuscles, the decrease of the latter being very marked.
1878.]
Bull, Study of Subconjunctival Serous Cysts.
85
Article V.
A Contribution to the Study of Subconjunctival Serous Cysts.
By Charles S. Bull, M.D., Surgeon^to the New York Eye Infirmary and
to Charity Hospital.
There are certain forms of cystic tumours, occurring beneath the con-
junctiva, chiefly of the eyeball but also of the eyelids, but which occupy
comparatively little room in the cavity of the orbit, and hence may be
separated from the larger and better known class of orbital cysts. They
are somewhat rare, and therefore have attracted but little attention, but
they seem to be worthy of a closer examination. In considering the na-
ture of these cysts, we must distinguish two forms : first, those in which
the space filled by the fluid is a natural cavity, that is, one developed
physiologically with the growth of the part; and second, those in which
the cavity is of new formation, from physiological disturbance or some
diseased process.
Virchow has taught us that in the same region cysts that are appar-
ently perfectly analogous may be of very different origin, and are there-
fore of varying significance.
According to Nelaton, cysts in and under the conjunctiva are developed
most often from the layer of tissue next the sclera, their size being very
variable, ranging from that of a pea to that of a walnut, and their origin
is at the best obscure. These cysts, never occupying much orbital space,
always develop forwards, pushing the conjunctiva before them, and hence
almost always admit of careful examination with the fingers. We thus
gain an insight into the consistence, surface, and mobility of the tumour,
and may make an exploratory puncture. Yet notwithstanding the com-
parative facility of examination, a diagnosis of the kind of tumour is not
always easy, for a growth, supposed to be a cyst from its softness and
fluctuation, may be accompanied by a solid growth. Moreover, lipomata,
as well as encephaloid cancers, very often give a sense of fluctuation under
the fingers. Another point of somewhat doubtful significance is the mo-
bility of such a growth. In the beginning, serous cysts are always movable,
and this freedom of motion may last some time, even when they are grow-
ing rapidly ; but generally they contract adhesions either with the con-
junctiva or with the periosteum of the orbit, and become more or less
firmly fixed.
Paget's division of cysts into simple or barren and compound or proli-
ferous, is a sufficiently good one for our purpose. These subconjunctival
cysts are always simple or barren: that is, they contain fluid or unorgan-
ized matter. They seem always to be formed by the enlargement and
union of the spaces in fibro-cellular and areolar tissues. As the fluid in
such a tumour collects and increases and the cavity enlarges, the wall of
86 Bull, Study of Subconjunctival Serous Cysts. [Jan.
partition between a number of such spaces breaks down, until finally we
have one large cavity. If the pressure of fluid continues, a point is
reached where the cavity gains a perfect wall or lining, and a pure fcyst
is formed from a pressing together and union of a number of connective
tissue trabecular which separated the original areolar spaces from each
other. If such a subconjunctival cyst is highly organized, and Ave have
been fortunate enough to remove it entire, or in greater part, it is found
on microscopical examination that the wall of the sac consists of fine fibro-
cellular tissue, which may run in a single layer, though more commonly
in several. Among these fibres are many nuclei, and the inner surface of
the sac is sometimes lined by a single layer of squamous epithelium. In
most cases, however, it is very difficult or next to impossible to remove
the cyst uninjured owing to its firm adhesions to the surrounding parts.
Sometimes, however, there does not seem to be anything like a cyst
wall ; but the fluid seems to have been poured out or secreted in the sub-
conjunctival areolar tissue, breaking down the trabecular, but apparently
not exerting enough pressure to bring about a condensation of the con-
nective tissue filaments into a distinct wall. Here the microscope shows
no lamination or stratification of the fibres, and of course no epithelial
lining. Some nuclei are indeed met with, but no more than might be
expected in any fibro-cellular tissue.
These cysts do not all contain a serous fluid, though most of them do.
Occasionally one is met with which contains an oily fluid. Mr. Hunter
cites a case of an oily encysted tumour which grew between the bony
orbit and the upper eyelid of a young gentleman, and its contents he
describes as "pure oil, perfectly clear and sweet." Schuh also relates
two cases of cysts under the brow, which contained similar oily matter.
Whence this oily secretion comes from it is still impossible to say.
Whether it is secreted as such, or whether it results from the fatty meta-
morphosis of the epithelium which lines the wall of the sac, is still an un-
solved question.
The causation of these cysts is still but little understood. In looking
for a cause in the tissue in which the tumour is met with, the ques-
tion of the local tendency or disposition comes up, and this tendency of
fluid cysts to develop in areolar connective tissue is well marked. Whether
heredity comes in as a factor is a matter of doubt in the particular class of
cysts under consideration. Though some of them are really congenital,
in the narrow sense of the word, yet the number of observed cases is still
so small that no statistics can be drawn from them. Hence the question
of heredity, as well of the tendency to the development of such cysts, as of
the actual growths themselves, must still be regarded as unsettled.
When these cysts have a sac-wall or enveloping membrane, it is some-
times excessively delicate, and resembles a serous membrane on its inner
aspect. Pathology seems to show that the cysts with moderately thick
1878.] Bull, Study of Subconjunctival Serous Cysts. 87
walls, which in some cases attain the thickness and density of the dura
mater, generally contain either sebaceous matter alone, or else sebaceous
matter and a dirty serous fluid mingled together. Demarquay considers
that this latter variety of cysts originates from the conjunctiva, and Walton
reports a case in a child of four years, in which the tumour extended
deeply into the orbit. (Demarquay, Tumeurs de I'Orbite, Paris, 1860,
p. 392.) As distinct from this variety, cysts are occasionally found secreting
their own contents, which owe their origin to certain canals, the orifices of
which have become more or less completely obstructed. Thus simple
serous cysts are met with in the eyelids, under the conjunctiva, and along
the edge of the tarsal cartilage, where they seldom acquire more than a
moderate size, and their removal is effected with little or no difficulty.
(Hodgkin, Med. Chirurg. Trans., xv., 1829.) This variety of cysts, how-
ever, consisting in abnormal dilatation of a normally existing tube or
cavity, from obstruction of its orifice, does not concern our subject.
We meet with these cysts most often among children and young adults.
In none of the cases which came under my observation was there any
history of injury of the region, nor in fact anything which could be attri-
buted as a cause ; thus differing from pure orbital cysts, where there is
almost always some history of blow or fall upon the orbit, which we are
accustomed to regard as a cause of the development of the cyst.
These fluid cysts occur either at the internal or at the external angle of
the eyelids, more often at the latter. Kerst thinks there is some connec-
tion between the contents of these tumours and the region where they
occur. He cites a case of subconjunctival encysted tumour, which occurred
at the side of the lachrymal gland at the external angle of the right upper
lid, and which was prolonged somewhat deeply into the orbit. It was
spherical or nearly so, the size of a chestnut, and contained a cloudy fluid
something like sebaceous or concentrated purulent matter, and a large
number of small hairs, resembling cilia. The cyst was removed entire.
Kerst thought there was a connection between the nature of the hairs
found in cystic tumours and that of hairs of the regions whence these
growths spring.
Another place where these cysts occur is that overlying or immediately
in front of the lachrymal sac, along the inner angle of the eyelids and side
of the nose. These pre-lachrymal cysts had not been mentioned in litera-
ture until Verneuil reported three cases to the Sociele de Chirurgie de
Paris, December 27, 1876, which were published in the Recueil d' Oph-
thalmologic for January, 1877. (See Am. Journ. of Med. Sci. for April,
1877, p. 549.) They have no direct connection with the lachrymal sac,
and their origin is in most cases probably congenital. Their contents
strongly resemble olive oil.
Verneuil' s first case was in a young man, and was situated in front of the lachry-
mal sac. It was as large as a cherry, was indolent, irreducible by pressure, and
of long standing. On being opened a liquid like olive oil appeared. No injection
88 Bull, Study of Subconjunctival Serous Cysts. [Jan.
of iodine was made ; the patient went away and never returned. His second ease
was in a young woman, aet. 19, and was also the size of a cherry. It stood a little
higher than the lachrymal sac, and the skin over it was greatly distended and very
thin. It dated back to early childhood. Its contents were also oily. The ante-
rior three-fourths of the cyst were excised, but the remainder, being very adherent
to the deeper parts, was left in situ. The wall was found covered by stratified
pavement epithelium. The liquid coagulated, and contained numerous crystals of
cholesterine and margaric acid. His third case was in a man, a±t. 31, was as large
as an almond, transparent, and dated from infancy. It was apparently adherent
to the periosteum. The cyst was punctured, two or three grammes of oily liquid
exuded, and after the cyst was entirely emptied, there was felt a small depression
in the bones at the inner angle of the orbit.
The origin of the oily contents is unknown. There are certain cysts
of the thyroid body and ovary which have similar contents.
Sichel gives two representations of serous cysts of the conjunctiva in his
Iconographie. One of them was communicated to him by Sommering,
and here the cyst was situated very closely to the lower border of the cor-
nea. From the symptoms and results this case, however, more properly
belongs to the class of orbital cysts.
Another interesting case is reported by Briere, in the Annee Medicale
de Ccen, II., No. 3.
The patient was a girl, ast. 1 7, in whom a small tumour had appeared in early
childhood at the inner angle of the right eye, just back of the caruncle, and had
slowly grown to the size of a walnut. A cyst was diagnosticated, opened, and
emptied of a clear serous fluid. The wound was then enlarged, and the entire
inner surface of the cyst cauterized by a saturated solution of the chloride of zinc.
This was repeated several times during a number of weeks. The cavity closed
very slowly, and was not entirely healed until live months had elapsed.
The following cases, each of which presented some peculiar features,
have been under my own observation during the past few years.
Case I. Subconjunctival Serous Cyst — Harry B., set. 4; first seen in
January, 1876. The child was sent to me from the country for a growth
in the orbit. About five months before, the parents had first noticed a
slight swelling at the external canthus of the right eye, and just below the
upper orbital margin. This slowly increased in size without causing any
pain or disturbance in mobility of the eyeball, until it has reached the
size of a flat Lima bean, which projects forward and downward from the
orbit. The conjunctiva was pushed before it, was freely movable over it,
and there was no increase of bloodvessels crossing it. The tumour could
be pushed backward somewhat into the orbit, and with the finger inserted
between it and the superior orbital margin, it was found that the growth
was adherent to the external and superior wall of the orbit. The tumour
was translucent, fluctuating, and movable ; and a diagnosis was made of a
fluid cyst. An exploratory puncture was made with a small trocar through
the most prominent part of the cyst, and about two drachms of a light
straw-coloured and perfectly clear fluid evacuated. The opening was then
enlarged horizontally, and an attempt made to dissect out the cyst. But
there was no distinct cyst wall to seize upon, and the adhesions Avere found
to be so broad and deep that the attempt was given up. A portion of the
cyst next the opening was snipped off and laid aside for microscopical
examination. A twisted strand of fine suture silk was introduced as a
means of drainage, the cavity being first carefully washed out by syringing
1878.] Bull, Study of Subconjunctival Serous Cysts.
89
with warm water, and the child was left in bed without any bandage.
Somewhat violent reaction followed the operation, owing to the attempts
made to dissect out the cyst; the conjunctiva became reddened and chemo-
tic, and the lids were hot and swollen. There was a free discharge of pus
through the wound on the second day, however, and all unpleasant symp-
toms then subsided. Pus drained away freely; the cavity gradually closed,
and at the end of the fourth week the little patient was discharged cured,
without there being any sign left of the previous existence of a tumour.
The eyeball was freely movable in all directions.
The portion of cyst which was removed was hardened in potas. bichrom.
solution, and then submitted to examination. The ordinary character-
istics of the subconjunctival areolar tissue were well marked, but there
was no sign of any attempt at the formation of a cyst wall. In places,
the connective tissue fibres were somewhat pressed together, so as to give
an appearance of greater density, and here and there was an agglomera-
tion of nuclei, but there was no arrangement of laminae in the course of
the fibres, and not a trace of any epithelium. There was nothing to point
to there having been any connection between the cavity of the cyst and
the lachrymal gland, nor was there anything found to suggest dilatation of
one or more of the excretory lachrymal canals. It seemed to have been a
collection of clear fluid in a formless space under the conjunctiva. The
fluid proved to be alkaline, slightly albuminous, and contained a few crys-
tals of cholesterine, but there was not enough of it to determine its spe-
cific gravity.
Case II. Subconjunctival Serous Cyst David F., set. 5, first seen in
April, 1877. A well-developed fair-haired boy, but not very bright. The
mother states that at the outer angle of the left eye there has been a small
tumour since birth, which increased very slowly in size up to six months
ago, since which time it has grown quite rapidly. It is now the size of a
large almond, projects decidedly beyond the orbital margin, pushing the
conjunctiva and lower lid before it, and is situated apparently in the in-
ferior cul-de-sac, in front of, and to the outside of the eyeball. The lower
lid is very prominent over the swelling. The surface of the tumour seems
to be pigmented, the conjunctiva is freely movable over it, and the motions
of the eye are unimpeded. The tumour is moderately firm, but fluctuating,
and can be moved in any direction. On examining the child more closely,
there was found a malformation of the left ear. There was a very small
and very much deformed concha, the lobe being entirely separated from it,
and no external auditory canal. The child always turns the other side of
the head to any one speaking, and a watch pressed against the rudimentary
concha is not heard, nor are the vibrations of a tuning-fork when held
close to that side of the head. When, however, a vibrating fork is placed
against the forehead or teeth, the child says he hears the sound on both
sides.
A diagnosis of a fluid cyst being made, an attempt was made to remove
it entire through a long horizontal incision. But though great care was
exercised in making the cut, the cyst had such very thin walls that the
pressure of a pair of forceps ruptured it at its most prominent point, and
a large quantity of colorless fluid escaped. The swelling almost imme-
diately subsided, and the lower lid resumed almost its normal position, but
there seemed to be considerable thickening of the areolar tissue about the
cul-de-sac. No drainage silk was used in this case, as I wished to see
whether the cyst would refill, but simple cold water dressings and a band-
90
Bull, Study of Subconjunctival Serous Cysts. [Jan.
age. There was no reaction at all, and the bandage was removed on the
second day. I saw the child the following week, and there was no appa-
rent change in his appearance, and the hypertrophied condition of the
subconjunctival tissue was about the same. Since then, the patient has
never returned, and I know nothing further of the case. The serous cyst
was probably of the same nature as the previous case, and had no distinct
cyst wall, but in regard to its origin it is somewhat different. The cyst here
was evidently congenital, was a deformity, and in view of the rudimentary
ear of the same side, it might be regarded as a malformation, but of what
seems difficult to say. It was probably not connected with the lachrymal
gland or its excretory ducts, for it was in the lower cul-de-sac. The left
eye itself was perfectly normal in every way.
Case III. Sab conjunctival Prelachryinal Cyst Maria M., a?t. 50,
first seen in February, 1877. The patient had always been in good health,
and had had very strong eyes till about two years back, when she caught
cold in her eyes, which became violently inflamed. From her description,
this was probably conjunctivitis of both eyes, with a subsequent dacryo-
cystitis on the left side. The lower canaliculus on this side had been slit
upland she said that a probe was passed for a long time. About eight
months ago she noticed a small swelling which made its appearance at the
extreme inner angle of the left eye, just above the caruncle, which, she
said, seemed to come down from under the upper lid. This tumour has
steadily increased in size, and has pushed the conjunctiva of the upper
cul-de-sac before it towards the eyeball, and has also pushed the skin for-
wards just above the internal tarsal ligament. On examination there is
seen in front of, and above the site of the lachrymal sac, a swelling the
size of a large walnut, of firm, resilient consistency, with no decided fluc-
tuation, which slips about under the fingers like a marble. The skin is
pushed forward over it, but is freely movable, showing that no adhesions
exist. The tumour also extends backwards and downwards towards the
eye, coming down between the upper lid at its inner angle and the eyeball,
pushing the lid away from the globe and the caruncle outwards and down-
wards. The conjunctiva is freely movable over it. There was still an occa-
sional discharge of pus from the sac. Pressure upon the tumour, however,
did not cause this, and there was a sensation felt under the finger which was
totally distinct from that felt in pressing upon a lachrymal sac filled with
pus. A diagnosis of fluid cyst was made, and an exploratory puncture
with a small trocar gave exit to about a drachm of slightly turbid, glairy
fluid. The trocar was introduced posteriorly through the conjunctival
cul-de-sac. The swelling immediately diminished very much in size, but
still not entirely, and a closer examination showed very decided thicken-
ing of the walls of the cavity. It was then determined to dissect out the
sac- wall if possible, and to this end a vertical incision was made externally
through the skin, reaching from the superior orbital margin down to the
internal tarsal ligament. The skin with the thin layer of subcutaneous
adipose tissue was carefully dissected away, and the fibres of the orbicular
muscle were then seen, somewhat thinned and separated by spaces, and
very pale. Underneath this was a yellowish-gray glistening appearance,
which could be easily separated and dissected up from the surrounding-
tissues. By working carefully with the handle of a scalpel and blunt
scissors, the cyst wall was finally removed entire after about half an hour's
work, and the hole found on its posterior surface where the trocar had
entered. Here the sac-wall lay immediately beneath the conjunctiva. On
1878.] Bull, Study of Subconjunctival Serous Cysts.
91
examining the cavity from which the cyst was removed, it was found to
lie, as suspected, directly in front of, and to the outside of the lachrymal
sac, from which it was only separated by a little adipose tissue. The
cavity Avas limited below by the upper margin of the internal palpebral
ligament, but above it reached nearly to the superior orbital margin.
There was considerable hemorrhage during the operation, and the oozing
continued until the cavity had been stuffed with small bits of sponge. A
probe was introduced into the lower canaliculus and passed readily to the
bottom of the nasal duct, proving that there was no obstruction, and that
the original operation for cure of the stricture had been effectual. Six
hours later, the pieces of sponge were removed and the cavity well washed
out with water. A strand of coarse suture silk was then introduced for
drainage purposes, and cold applications made. There was very little
reaction, the cavity began to granulate from the bottom, the discharge of
pus was moderate, and on the twenty-fourth day the patient was discharged
with the wound entirely closed, very little prominence of the skin over
the seat of the tumour, and not a very marked linear cicatrix.
The fluid was albuminous, neutral in reaction, and contained cholesterine
crystals. *
The cyst presented a smooth, glistening appearance on its internal
surface, but was rough and uneven on its exterior, owing to the divided
and broken adhesions. Its wall was about half a line in thickness. After
hardening in a solution of potassium bichromate, and then in alcohol,
sections were made of the cyst wall and placed under the microscope.
It proved to be composed entirely of well-developed connective-tissue
fibres, densely packed together, witli well-marked nuclei, and here and
there some free nuclei. There was no distinct lamination, but the fibres
appeared to run parallel to one another, and as closely as is met with in
the sheaths of tendons. The inner surface was covered by a single layer
of pavement-epithelial cells, each with a distinct nucleus. The outer
edge of the sections showed where the looser areolar tissue, forming the
adhesions, had been broken away by the process of dissection.
The origin of this cyst it seems impossible to determine. I could see
no connection between its development and the dacryocystitis which had
existed for some time. There was no history of any injury, such as
occasionally gives rise to orbital serous cysts, and there is no bursa in this
region which might develop into a cyst from hypersecretion of its contents.
Case IV. Subconjunctival Cyst of the Caruncle Patrick M., set. 12,
first seen in April, 1874. The patient is a well-developed Irish boy, who
had never had any trouble with his eyes, except this tumour, until within
a few weeks. The parents stated that in early infancy a small swelling
had appeared at the inner corner of the right eye, and had very slowly
increased in size, but had never occasioned any trouble, nor had the eye
ever been red or inflamed. About two weeks before I saw him, the child
was attacked by an ordinary catarrhal conjunctivitis, for which he was
brought to the infirmary. Since then, the mother said, the swelling had
grown more rapidly, had become red, and was somewhat painful. On
examination I found a small, red, fluctuating tumour, about the size of a
large bean, occupying the site of the caruncle of the right eye, freely
movable and sensitive to the touch. The pain was probably due to the
pressure upon the inflamed conjunctiva. Supposing this to be a colloid
cyst of the caruncle, which are not uncommon in this situation, the cyst
was punctured with a broad needle. The moment the needle was with-
02
Bull, Study of Subconjunctival Serous Cysts.
[Jan.
drawn, a small quantity of clear serous fluid was poured out and the
tumour collapsed to less than the size of the normal caruncle. The con
junctivitis was then treated in the ordinary way by weak solutions of
alum, but on the fourth day the cyst was as large as ever. The contents
were again evacuated as before, but the cyst again refilled, and on the
ninth day, after puncturing it, the opening was enlarged, and the inner
surface of the sac cauterized by a fine pencil of nitrate of silver. This
caused suppuration of the sac, which soon, however, ceased, the cyst con-
tracted and eventually disappeared almost completely, and gave the appear-
ance of a deeply sunken caruncle, such as we sometimes see after tenotomy
of the internal rectus for convergent squint.
Case V. Serous Cyst of the Caruncle — Sophie S., set. 40, first seen in
September, 187G. This patient had never any affection of the eyes until
six months ago, when she first noticed a little protuberance of a pearly
colour at the internal canthus of the right eye, which slowly increased in
size. There was never any pain or redness of the part. When I saw
her there was a swelling the size of a bean, situated just in front of the
caruncle of the right eye, which pressed forward and downward upon the
lower canaliculus and caused considerable epiphora. Having forgotten
the occurrence of the previous case, which resembled this very closely,
except in the one particular of coming on in adult life, a diagnosis was
made of colloid cyst of the caruncle, and the tumour was punctured.
Instead of a colloid mass exuding, a clear serous fluid made its appearance,
and the swelling collapsed. I then recalled to mind the other case, and
was consequently prepared to see this cyst fill up again. To avoid this,
the opening was enlarged and the interior of the sac cauterized, as in the
preceding case. The result was the same — moderate reaction, suppuration
for a few days, then closure and contraction of the cyst wall, and no return.
The development of a serous cyst in the lachrymal caruncle, as exempli-
fied by these two cases, is somewhat singular. Anatomically considered,
the caruncle is an aggregation of small hair follicles, held together by
connective tissue, with sebaceous glands and fat cells lying between the
follicles. Colloid and sebaceous cysts might naturally be expected here,
and do occur, and even small fatty tumours are occasionally met with,
but I am not aware of any case of serous cyst of the caruncle having been
previously reported. From the rapid contraction of the cyst walls, and
the deep sinking-in of the remainder of the tumour after final evacuation,
it is probable that the original constituents of the caruncle had been
absorbed more or less completely and their space occupied by fluid, and
this being discharged, nothing remained but an extremely thin outer layer
or surrounding membrane, and hence the very small size of the caruncle.
47 East Twenty-third St., Oct. 4, 1877.
1878.]
For mad ? Distribution of Nerves in the Iris.
03
Article VI.
The Distribution of Nerves in the Iris. By Henry F. Formad, B.M.,
M.D., of Philadelphia. (Abstract from #n Inaugural Prize Essay, presented
to the Medical Faculty of the University of Pennsylvania.)
The iris is an open field for research ; neither its histological structure
is settled beyond doubt, nor is the exact modus operandi of its move-
ments satisfactorily proven. A large number of distinguished writers on
this subject express the most diverse views, as a glance at its literature
will show.
Having made a number of microscopical researches on this subject, it
is my intention at this time to speak of the nerves only in so far as re-
gards their mode of distribution in the iris. In my opinion, all existing
descriptions of the nerves of the iris are incorrect, and, indeed, but super-
ficial work has been done in this department.
Passing over the theories of the ancients, who substituted for the func-
tion of the nerves of the iris affluxes of "spiritse animalis," etc., or such
curiosities as the view of Bartolini1 in 1643, who considered the ciliary
nerves as peculiar ligaments, to which he ascribes the property of contrac-
tility and expansibility, which cause the movements of the iris, we meet,
as early as in 1727, the admirable paper of Petit.2 In this he describes
his discovery that by section of the sympathetic at the neck, paralysis
of the dilator muscle of the iris resulted, thereby allowing an increased
action of the sphincter, causing contraction of the pupil. But the honour
of having first described the nerves in the iris proper, must be conceded
to Saint Yves,3 of Paris, in 1744, who is not quoted by any writers on
this subject. His description of the nerves concerned is by no means
less satisfactory than those given by some of the most prominent authors
of our day, e. g., in the recent edition (1875) of Henle's large Anatomy.4
Saint Yves's description leads me to believe that he really saw nerves
in the iris, and the fact, that there existed in his time a few very satis-
factory microscopes, is also a support to this opinion. In 1845, M. S.
Weber,5 of Leipsic, a distinguished anatomist, absolutely denied the ex-
istence of nerves in the iris, which were so admirably observed over one
hundred years prior. During these one hundred years, the existence of
such nerves was also either doubted or overlooked by several other promi-
1 Cornellius Bartholini : Archiatri Danici Anatome. Lugduni, 1643.
2 Petit, M. : Memoires de l'Academie Royale des Sciences. Paris, 1727.
8 Saint Yves (Surgeon Oculist of the Company of Paris) : A New Treatise on Dis-
eases of tlie Eyes, containing some new discoveries in the structure of the eye.
Transl. from the French by J. Stockton, M.D. London, 1744. See pp. 13, 20, and 36.
4 J. Henle : Handbuch der System. Anatomie des Menschen. B. ii. Braunschweig,
1875, p. 663.
5 Weber, M. S. : Handbuch der Anatomie des Menschlichen Korpers. Leipzig, 1845.
See "Iris."
94
Forma D, Distribution of Nerves in the Iris.
[Jan.
nent observers, such as Sommering,1 Muck,2 Doellinger,3 Home,4 and
others (probably from using material which had undergone cadaveric
change or employing imperfect methods) ; and on the other hand they
were claimed as being discovered by Zinn5 (1755) ; but he probably mis-
took bloodvessels for nerves, as would appear from fig. 1, tab. iv. of his
otherwise excellent treatise on the eye. This very old drawing of Zinn,
or sometimes a similar one, is used unaltered, even in modern anatomical
works, to illustrate the " nerves of the iris and choroidea." Other old au-
thors, as Porterfield6 and A. Monro,7 describe much more satisfactory
observations on the nerves concerned. Schreger,8 of Leipsic, considered
the shape of the pupil of various animals to be dependent upon the ar-
rangement of the nerves in the iris. Treviranus,9 also a prominent ob-
server, is mentioned by some as having first described the nerves of the
iris. Two excellent American authors in connection with my subject I
may mention : W. C. Wallace,10 of New York, the first discoverer of the
ciliary muscle, and S. M. Gibson, 11 of Baltimore.
The older literature is, in general, very interesting ; it exposes some of
the most important observations, long ago made but since forgotten. But
not all of them deserve consideration ; the late distinguished anatomist,
Friedrich Arnold,12 of Heidelberg (1832), and several others profess to
have seen nerves in the iris of man and smaller creatures with the
naked eye, or by a magnifying power of only two and a half diameters. I
have convinced myself that it is impossible to recognize nerves in the iris,
beyond doubt, with lower magnifying power than fifty or even sometimes
five hundred diameters. I admit, however, that Mayer13 has seen with
1 Sommering;, Sam. Th. : Icones oculi humani. Tranc. ad Moenum, 1804.
2 Muck, G. : De Ganglio Ophtkalomico et nervi ciliaribus. Landishuti, 1815.
3 Doellinger, J. : Illustratia iconographiea fabricse oculi humani. Berlin, 1817.
4 Home, Ev. : Philosophical Transactions of 1822, part i. p. 76. London.
5 Zinn, Joh. G. : Descriptio Anatomica oculi humani, iconibus illustrata. Goltin-
gen, 1755.
6 Porterfield, W. : A Treatise on the Eye. Edinburgh, 1759. See Iris.
I Monro, A. : Human Anatomy. Edinburgh, 1795, p. 100. Three Treatises, on the
Brain, Eye, and Ear. Edinb., 1797, p. 109.
8 Schreger, Ch. : Versuch einer vergl. Anatomie des Auges des Menschen und der
Thiere. Leipzig, 1810.
3 Treviranus, G. R. : Beitrage ziir Anatomie & Physiologie der Sinneswerkzeuge des
Menschen & der Thiere, illustrirt. Bremen, 1828. See vol. i. p. 77.
10 Wallace, W. C. : The Structure of the Eye. New York, 1836.
II Gibson, J. M. : On the Anatomy and the Diseases of the Eye. Baltimore, 1832.
" Arnold Friedrich : Anatomische & Physiologische Untersuchungen iiber das Auge
des Menschen. Heidelberg, 1832.
13 Mayer : Anatomische Untersuchungen iiber das Auge des "Walfisches, etc. Bonn,
1852. Of older authors I would further, for a full study of the subject, recommend as
very valuable the following : —
C. Krause: Handbuch der menschlichen Anatomie. Hanover, 1833, vol. L p. 2d, p.
532. — Valentin, G.: Ueber den Verlauf & die letzten Endigungen der Nerven. Nova
acta Physico-medica Naturalis Curiosum, 1836. See page 110 and tab. v. fig. 28. —
Handle, L.: Anatomie Microscopique. Paris, 1838, vol. i. tab. 42. — Quain, S.: Elements
1878.]
Formad, Distribution of Nerves in the Iris.
95
the naked eye these nerves in the whale, which he describes in his excel-
lent paper. Several of the older anatomists advised that no reliance be
placed upon the microscope, as it frequently " deceives," and declared an
ordinary magnifying lens as sufficient for histological examinations, by
Avhich means they discovered or denied *the existence of ganglionic cells,
etc., in the iris.
Budge1 has written an excellent monograph on the movements of the
iris ; there is nothing equal to it even in recent literature. Budge's mi-
croscopic examination of the nerves could, however, not have been a
satisfactory one, for his method involved the use of strong solutions of
caustic potassa, which I have found partly destroys the nerves. The
descriptions of these nerves, given by Kolliker2 and by Eiidinger,3 I find
to be incorrect. Fig. 472 of Kolliker's Gewebelehre (1. c), which is in-
tended to illustrate the distribution of the nerves in the iris, gives an en-
tirely wrong idea ; it is the same old drawing Kolliker gave twenty-five
years ago,4 which we also find reproduced in every edition of Quain's
Anatomy. A short but peculiar description of these nerves is given by
Dr. A. Metz,5 of Cleveland, Ohio ; he does not, however, mention his
authority.
Hirschfeld,6 in conjunction with Robin, dogmatically asserts that
" there are but very few nerves in the iris, and that those who pronounce
this organ to be richly supplied with nerves are wrong."(!)
Of the recent special text-books and monographs, none contain anything
new ; the most of them give a description of the nerves of the iris, if any,
according to Julius Arnold,7 seldom referring to any other author. In-
deed, no one treats the subject more exhaustively, in an anatomical point
of view, than J. Arnold (1863), and nothing original has been written
since.
One of the disputed points in connection with the nerves of the iris, is
of Anatomy. London, 1837. See Iris. — Pappenheim, S. : Specielle Gewebelehre des
Auges. Breslau, 1812.— Hrtschlce, B. : Encyclopedic Anatomique. Paris, 1815, vol.
v. p. 651. — Eyrtl, S.: Lehrbuch der Anatomic Prag\, 1816. See Iris. — Brucke:
Anatomische Beschreibung des menschl. Augapfels. "Berlin, 1817.— Beck, K. S. :
Ueber die Verbindung der Sehnerven mit dem Augen und Nasenknoten. Heidelberg,
1817. — BocMaleck: Prager Vierteljahrschrift fur practisehe Heilkunde, 1850, 7th year,
p. 163. — Kolliker, A. : Mikroscopische Anatomie. Leipzig, 1853. See Iris. Be Buiter :
De Actione Belladonge in irid. In Trajecta ad Rhennm. "Utrecht, 1853, p. 4. See also
Nederlandsch Lancet, d. iii. p. 135.
1 J. Budge : Ueber die Bewegung der Iris. Braunschweig, 1855. (It is out of print
and impossible to obtain ; there exists a copy, among other rare books in this line, in
the private library of Prof. Wm. F. Norris, to which I had access through the kind-
ness of its owner.)
9 A. Kolliker : Handbuch der Gewebelehre. Leipzig, 1867. See Iris. '
* Rudinger : Anatomie der Gehirn-Nerven. Mtlnchen, 1868.
4 A. Kolliker : Mikroscopische Anatomie. Leipzig, 1852.
5 A. Metz : Anatomy and Histology of the Human Eye. Philadelphia, 1868.
G L. Hirschfeld : System nerveux. Paris 1866. See p. 44-9.
7 Julius Arnold : " Ueber die Nerven.und das Epithelium der Iris." In Virchow's
Archiv, 1863, vol. xxvii. p. 315, and plate vii.
96
Form ad, Distribution of Nerves in the Iris.
[Jan.
the existence or non-existence of ganglia, which Meckel1 claims to have
discovered. Their existence was afterward confirmed by Treviranus,2
C. Krause,3 Bochdalek,4 Mayer,5 and others ; J. Arnold6 also found " gan-
glion-like masses" in the iris of the rabbit.
Donders,7 who coincides with Samisch, Schweiger, H. Miiller, Lie-
breich, W. Krause, and Manz, in admitting ganglia of the ciliary muscle,
says, that ganglia, probably, also exist in the iris. Quite modern writers,
such as Dr. Gradle8 (of Chicago) and Dr. Faber9 (of Leipsic), declare
also, very positively, that ganglia do exist in the iris of man and other
animals. Gradle does not claim to have made any researches of his own,
nor does he mention on what he bases his statement ; and Faber's observa-
tions on the nerves were very superficial, and I also strongly suspect that
he has mistaken bloodvessels for nerves, in describing the latter, as he
used hydrochloric acid, which brings out the vessels very prominently,
but is one of the poorest reagents for nerves ; I have convinced myself of
this fact after many trials, using hydrochloric acid in every degree of dilu-
tion.
Opposed to the existence of ganglia in the iris, are Buschke,10 Budge,11
Kolliker,12 Rudinger,13 and Michel. u
Describing the nerves of the iris, I coincide with J. Arnold,15 in general,
more or less ; but in three very important points I am entirely opposed to
him : 1, in the mode of entrance of the nerves into the iris; 2, their mode
of distribution in the outer (the ciliary) part of the iris ; and 3, I deny
his " ganglion-like masses."
For the investigation of the nerves, I have heretofore used, satisfactorily
only, the irides of Albino rabbits ; partly also of the sheep and of the cat,
with more or less similar results in all. Human irides (which are sup-
posed to have the same arrangement of nerves as those of the rabbit) I
have examined immediately after they were extirpated at the clinic, but
they were, probably, not sufficiently healthy, as I got no satisfactory
results.
My conclusions I draw from over fifty preparations of nerves of the
iris of the rabbit, which I still have in my possession. I have used all
the methods and reagents ever suggested for nerves, with more or less
1 Fr. Meckel : Handbuch der menschl. Anatomie. Halle, 1S15. Vol. iv. p. 86.
2 3 4 8 6 Loc. cit.
7 F. C. Donders : On the Anomalies of Accommodation and Eefraction of the Eye.
Transl. of Syd. Soc. London, 1864, p. 576.
8 H. Gradle: "The Movements and Innervation of the Iris." In the Chicago
Journal of Nervous and Mental Diseases, April and July, 1875.
8 C. Faher : Der Bau der Iris des Menschen und der Wirbelthiere. Gekrohnte Preis-
schrift. Leipzig, 1876, p. 34.
io u ii 13 Loc> cit,
14 J. Michel : Die histologische Structur des Iris-stroma. Erlangen, 1875.
15 Julius Arnold : loc. cit.
§
1878.] Form ad, Distribution of Nerves in the Iris. 97
similar results. I will not enter upon a consideration of them, but will
here only state, that I found best, maceration in a 2 to 5 per cent, solution
of acetic acid for 12 to 48 hours, followed by a subsequent immersion in
highly dilute (0.1 per cent.) solution of chromic acid for half an hour. For
staining, I used Beale's carmine-solution (or htematoxylon staining), and as
a preservative, glycerin, with the best results. I would also recommend a
slight heating of the preparation during examination under the micro-
scope, as it brings out the nerves often surprisingly well where they were
not previously visible. I also found the use of chlorine- water (recom-
mended long ago by Grunhagen, but since forgotten, as no records of its
use could be found) for pigmented irides of great service ; chlorine-water,
bleaching the pigment entirely after maceration for several days, and subse-
quent maceration in glycerine, does not influence the structure of the iris
at all. This method could be used, I think, advantageously in all cases
where pigment obscures a tissue. For the examination of the elementary
termination of the nerves, I used the usual gold-method.
By the above-mentioned method, the nerves acquire such a character-
istic, striated appearance, that it is impossible to mistake them. The
bloodvessels are also very distinctly seen in the preparations, and are
easily distinguished from the nerves, as are also the connective-tissue and
muscular fibres, etc.
The nerves do not lie all in one plane, but in different layers of the
structure of the iris. Placing the iris on either side, the nerves can all
be seen as I have drawn them, some only by constantly moving or alter-
ing the focus. Doubtless also more networks of small nerves exist than I
have drawn. Most of the larger nerve-trunks lie (the iris being examined
from the anterior side) in front of the bloodvessels running usually at some
distance from the latter, but often parallel with them.
The wood-cut represents about T\ of the circumference of the iris in its
whole breadth ; a part being selected where the most peculiar and variously-
shaped nerve plexuses occurred.
The distribution of the nerves may be described as follows : —
The nerves enter the iris from the ciliary muscle through its outer
peripheral border in comparatively small trunks, and form, if we divide
the iris in its breadth into four equal parts or zones, in the first or
outer zone, often very near and parallel with the ciliary border, an irre-
gular dense circular plexus of larger nerve-trunks, which goes around the
whole circumference of the iris. A second circular plexus which forms
more arches, the convexity of which is directed sometimes towards the
ciliary and sometimes towards the pupillary border, runs through the
second zone. A third circular plexus of the same character as the fore-
going, but being more irregular, runs through the third zone. In the
fourth zone, which also includes the sphincter, run a fourth and a fifth
circular plexus composed of thinner nerve-trunks, but of the same character
No. CXLIX Jan. 1878. 7
98
%
Form ad, Distribution of Nerves in the Iris.
[Jan.
1878.] Form ad, Distribution of Nerves in the Iris.
90
as the foregoing ; the fifth being in the sphincter itself runs very near the
pupillary border. All these five somewhat irregular circular plexuses, being
more or less parallel with the ciliary and the pupillary borders, are con-
nected M'ith one another by transverse or radiating nerve-trunks of
tolerably large size. Most of these radiating trunks originate in the first
circular plexus and go direct to the second ; others continue their course
isolated, crossing the second and sometimes also the third circular plexus,
divide themselves, sometimes dichotomously, or unite with some other
nerve-trunk, then form an arch or a loop and finally join one of the
plexuses. This is repeated over and over again in an irregular manner
all over the iris, so that the formation of arches, and loops, and triangles,
may be considered as predominating in the distribution of the larger nerve-
trunks. These consist chiefly of medullated nerve-fibres with distinct
neurilemmas and prominent nuclei in the latter. At the decussation and
junction of two or three nerve-trunks, there are formed sometimes peculiar
figures as represented in the drawing. An intimate interchange of nerve-
fibrils of the different nerve-trunks usually takes place at such points.
From all larger nerve-trunks which enter into the formation of the cir-
cular plexuses, and still more from the convex side of the arches and loops
formed by the radiating trunks, smaller nerve-trunks of a mixed elementary
character take their departure, which, in a similar way unite to form
plexuses ; from these still smaller nerve-twigs arise, which freely inoscu-
late one with another, and finally dividing into their primitive fibrils form
a terminal netivork all over the iris, which is- in intimate connection with
all elements of the structure of the iris. No ganglionic cells could be
observed in the iris.
I never succeeded in finding any ganglia, but I have frequently seen
conglomerations of protoplasm, on and between several nerve-trunks, which
probably have been confounded with ganglia, and which have been called
also " ffano-l ion-like masses." Some of the stellate connective tissue cells
in the iris and neuroglia-cells, especially when surrounded by protoplasm,
may also be confounded with ganglia. In connection with this I may
mention that, recently Sgm. Mayer1 declared the nuclei of the sheath of
Schwann to be true ganglia. (!)
J. Arnold2 failed to see the first circular plexus near the ciliary border,
as his description and his drawing show. It is true that this plexus is
not visible with equal distinctness in every part of the circumference of
the iris, being sometimes somewhat indistinct, but I never missed it in
successful preparations of entirely fresh irides. No description of this
first plexus has, heretofore, been published. De Ruiter (loc. cit.), who
investigated the iris of the white rabbit ten years prior to J. Arnold,
1 Sgm. Mayer: "Die peripherische Nerven Zelle und das Sympathische Nerven
System." Berlin, 1876.
3 Julius Arnold, loc. cit.
100 Munde, Ovariotomy during Peritonitis. [Jan.
describes a plexus of nerves " near the margin of the iris, whence smaller
branches take their origin," which could, perhaps, correspond to the first
plexus of my description, but, as he considers only one more in the iris,
namely a second near the sphincter, it is probable that he saw the second
(Arnold's first) circular plexus, which is much more readily observed.
Certain it is that De Ruiter's observation is a valuable one, and should
have received attention, as it, so far as the mode of entrance of the nerves
into the iris is concerned, approaches nearer the truth than any other.
A correct knowledge of the mode of distribution of the nerves may,
perhaps, throw some more light on the physiology of the movements of
the iris.
I am indebted to Dr. E. O. Shakespeare for much practical advice
during the progress of the above observations, which were made in the
summer and autumn of 1876, in the Pathological and in the Eye Labo-
ratories of the Medical Department of the University of Pennsylvania.
Article VII.
A Case of Ovariotomy during Subacute Peritonitis and Suppura-
tion of the Cyst following Aspiration ; with Remarks. By Paul
F. Munde, M.D., Assistant Surgeon to the New York State Woman's Hos-
pital.
This case possesses, as the heading indicates, several features of inte-
rest, which lead me to report it, and to which I shall briefly refer after
concluding the history of the case.
Isabella McC, 33 years of age, single, of small, slender figure, came to
me October 20th, 1875, with an abdominal tumour, which, she stated, had
grown within the last six weeks, and which caused her great discomfort.
On thorough examination the tumour was declared to be an ovarian cyst
proceeding from the left ovary, for I could distinctly feel the prolapsed
right ovary per rectum. The vagina was virginal, a perfect hymen pre-
sent, the uterus anteflexed and pressed down into the pelvis by the abdomi-
nal tumour, which distended the abdomen to about the size of a pregnancy
at the eighth month. Dr. Clement Cleveland, whom I asked to see the
case with me, agreed in the diagnosis. A radical operation being posi-
tively refused, we agreed to relieve the inconvenience which the tumour
caused the patient, and which was out of proportion to the size of the
growth, by tapping it with the aspirator, not anticipating any evil results
from the operation, and hoping by the time it filled again to induce the
patient and her friends to consent to its removal. Accordingly, November
2d, with the assistance of Dr. M. D. Mann (Dr. Cleveland being pre-
vented), I introduced a medium-sized aspirator needle into the median line,
and readily withdrew three quarts of a thick grumous fluid, which under
the microscope presented the characteristic appearance of ovarian fluid
(granular corpuscles, epithelial cells, diffuse granular matter, oil-globules,
1878.]
MundEj Ovariotomy during Peritonitis.
101
etc.), and coagulated almost entirely by heat and nitric acid. The remo-
val of this fluid permitted the clear mapping out of the tumour, and the
distinct recognition of a more or less solid portion posteriorly, and on the
right side.
The condition of the patient remained perfectly satisfactory six days
after the paracentesis, but then she began to complain of severe pain
in the abdomen, her pulse rose to 120, and her strength became so much
prostrated as almost to lead me to fear a rapid death from collapse. At
the same time the cyst refilled with astonishing rapidity, and ten days
after the tapping, exceeded its former size. The abdomen was exceed-
ingly tense, tympanitic above the umbilicus, but not particularly sensitive
to pressure. I first attributed this sudden collapse to the rapid refilling of
the cyst and the accompanying drain of albumen from the system, and
endeavoured to sustain her strength by tonics and stimulants until she
should have recovered sufficiently to permit the operation. It soon be-
came apparent, however, that the patient was in a low typhoid condition,
and that in all probability suppuration of the cyst had taken place. The
pulse remained about 120 and weak, the distension of the abdomen in-
creased rapidly, and the abdominal parietes became mottled, and showed
slight oedema, the patient's strength was evidently failing, and I saw that
the woman would certainly die within a few days if she were not at once
relieved by operation ; I therefore consulted Dr. T. G. Thomas as to the
advisability of giving her the one chance of recovery remaining, that is, of
performing ovariotomy at once, in spite of her extreme prostration. Dr.
Thomas strongly advising this procedure, I gained the consent of the rela-
tives, but previous to operating requested Dr. Thomas to see the patient.
This he very kindly consented to do, and on Sunday, November 14th, at
10 A. M. made a thorough examination of her condition, at the close of
which he informed me that the abdominal tension was so great that
neither externally nor per vaginam could he detect the outlines of an
ovarian tumour, but that taking the correctness of my diagnosis for granted,
he would certainly advise immediate ovariotomy as the last and only hope
for the patient. As a precautionary measure he would, however, recom-
mend a .small quasi exploratory incision, which could be enlarged on
reaching the peritoneal cavity, and verifying the presence of an ovarian
tumour.
Before deciding on the hour for operation, I introduced a hypodermic
needle at four different spots into the transverse colon, as I supposed,
where the tympany was most marked, for the purpose of withdrawing some
of the air which rendered percussion above the umbilicus tympanitic in
every position of the body, and then mapping out the present outlines of
the tumour. Through none of these punctures, however, did air escape,
and only a few drops of clear serum flowed from the canula.
At 2.30 P. M. of the same day I proceeded to operate, with the assist-
ance of Drs. Cleveland, Mann, G. W. Porter, Paine, and Saunders. Before
the operation, the pulse was 120, the temperature 99.5°. When she was
placed on the table, Dr. Porter, of the "Woman's Hospital, who kindly
volunteered to take charge of the anaesthesia, found the pulse so low that
he hesitated to administer the ether. After about one dozen hypodermic
syringefuls of whiskey had been administered, the pulse rose consider-
ably in strength and continued to do so as the patient came under the
influence of ether, which was given rather sparingly during the operation,
merely keeping her sufficiently narcotized to render her insensible to pain.
102
Munde, Ovariotomy during Peritonitis.
[Jan.
Twice when the face became pallid and syncope appeared imminent, ten
drops of the nitrite of amyl (wrhich I had brought with me for such an
emergency) administered on a handkerchief at once restored the rapidity
of the cerebral circulation and stimulated the action of the heart, as
evinced by the flushing of the face and the increased fulness of the pulse.
When anaesthesia was complete, I made an incision one and a half inch
long in the median line down to the peritoneum, and while lifting up that
membrane with the forceps, and endeavouring to push a director between
it and the tumour, the peritoneum and cyst-wall being closely united by
diffuse fresh adhesions, the cyst burst and its contents were discharged.
I now rapidly enlarged the incision upwards and downwards to three and
a half inches, detached the numerous fresh adhesions, which I found
extending even into the pelvis, applied a firm figure-of-8 quadruple silk
ligature to the pedicle, put on Spencer Wells's clamp, and removed the
tumour, which I found to arise from the left ovary, as I had predicted.
The tumour was an oligocyst, consisting of one large and several small
cysts, and a solid mass of the size of a child's head. Its wall, both exter-
nally and internally, was intensely congested and covered with fresh
inflammatory deposits; the cyst fluid was purulent and offensive, with
masses of fibrine varying from a pea to a lemon in size floating in it. Both
the visceral and parietal peritoneum were of a dusky-red hue, and covered
with numerous ragged patches of fresh lymph, to which the tumour had
been adherent.
After removing the cyst the abdominal cavity was rapidly cleansed
(there was some slight oozing from the torn adhesions, but none sufficient
to require ligation), but I fear not as carefully as should have been done, had
not the still extremely feeble condition of the patient led me to hasten the
completion of the operation as much as possible. Indeed I may well say,
and the gentlemen present fully concurred with me, that during the whole
operation I was in constant apprehension that the feeble fluttering pulse
might suddenly give out and the patient die on the table. Without the
hypodermics of whiskey and the amyl-nitrite, I doubt not that this would
have occurred. Without, therefore, removing every trace of the soft adhe-
sions and flocculent deposits on the peritoneum, as I should have done had
I been less hurried, I made haste to close the abdominal wound by silver
wire sutures applied in the ordinary manner, securing the pedicle with the
clamp in the lower angle of the wound, passed a medium-sized Thomas'
glass drainage tube into Douglas's pouch immediately above the pedicle for
the purpose of making disinfectant intra-peritoneal injections, and finally
covered the abdomen with sheets of cotton batting properly strapped and
bandaged down. It was with a feeling of intense relief that I, after the
lapse of scarcely more than twenty minutes from the first incision, removed
the (living) patient from the table and placed her in the bed prepared for
her. She was fully conscious, and expressed herself as feeling very com-
fortable. Bottles of hot water were put to her feet, a regular course of
stimulants (brandy and milk punch), quinia, and beef-tea was ordered, in
accordance with the needs and capacity of the patient. The subsequent
history of the case is briefly as follows : —
Nov. 14. 4 P.M., immediately after the operation pulse 120, temp.
98°. 8 P. M., pulse 128, temp. 89.5°, in axilla.
15th. 10 A.M., pulse 128, temp. 100.5°. Passed a very good night.
8 P.M., pulse 128, temp. 100.3°.
lQth. 10 A. M., pulse 132, temp. 102°. Night rather restless. On
1878.]
Munde, Ovariotomy during Peritonitis.
103
opening the tube an offensive odour escaped from the peritoneal cavity.
An injection was therefore made of two quarts of warm salt water, con-
taining gr. x salicylic acid to the pint, and this was repeated regularly
three times every day. 5 P. M., pulse 140, temp. 103°. 12 M., pulse
152, temp. 102.5°. Two hypodermics of quinioe bisulph. grs. 3 each.
11th. 9-J- A.M., pulse 140, temp. 100.5°. Was delirious occasionally
during the night ; now perfectly conscious, and feels well. Pulse strong ;
no peritonitis. Was seen by Dr. Thomas, who expressed surprise at seeing
her looking so bright, and gave hopes for her recovery. 4 P. M., pulse
140, temp. 100.5°. Quiniae bisulph. grs. 3 hypodermically. 8 P. M.,
pulse 136, temp. 100°.
ISth. 10 A.M., pulse 132, temp. 99.2°. 7 P. M., pulse 140, temp.
100.2°. Has had three spontaneous alvine evacuations without pain.
Tr. opii, digitalis and hyoscyami were given, aa gtt. xx.
l^dth. 10 A.M., pulse 148, temp. 101°. Great change; complexion
pale yellow; cold perspiration; large parotitis of right side. Evidently
septic pyaemia. Case hopeless. Discharge from tube very fetid ; strength
of injection doubled, tr. opii against diarrhoea. Digitalin (Merck's) gr. ^
hypodermically to reduce pulse. 2 P.M., pulse 152, temp. 102°. 8
P.M., pulse 172, temp. 102°. Moribund.
20^. 5 A.M., died.
A post-mortem meeting with objections on the part of the relatives, and
not being likely to afford much additional information, was not insisted
upon.
The several features of interest and importance to which I alluded
ar e : —
1. The occurrence of peritonitis and inflammation of the cyst, and
decomposition of its contents after the simple operation of aspiration.
2. The performance of ovariotomy during the existence of peritonitis
and oophoro-cystitis, and
3. Incidentally, the influence of the nitrite of amyl in stimulating the
action of the heart and counter-acting whatever depressing effect the long-
continued administration of sulphuric ether might produce.
1. Peritonitis and Oophoro-cystitis following -Aspiration Before
ovariotomy became a recognized and common operation, the only relief
afforded sufferers with ovarian cysts consisted in removing the fluid by
tapping with an ordinary trocar, an operation which was, therefore, very
frequently performed, and looked upon as almost innocuous. Even at the
present day it is a common occurrence, particularly in rural districts, and,
probably, there is scarcely an older practitioner who does not remember
having done it once or oftener. But statistics show that it is by no means
so harmless a procedure as the immunity from danger through it enjoyed
by the majority of ovarian tumours would lead us to suppose. Besides
inducing a rapid reformation of the cyst contents, and consequent exhaus-
tion of the patient, quite a number of cases died undoubtedly in conse-
quence of the puncture itself. Thomas1 cites a table by Fock, of Berlin
Diseases of Women, 1874.
104
Munde, Ovariotomy during Peritonitis.
[Jan.
according to which of 132 cases of tapping 25 died within a few days, and
of 20 cases by Southam 4 died within a few hours. Of 130 cases of tap-
ping collected by Kiwisch 17 per cent, died within several days. This
large mortality from an operation which, except in the rarest instances,
affords but temporary relief, naturally led the profession to hail in the aspi-
rator of Dieulafoy a safe and equally efficient substitute, by which the
entrance of air into the peritoneal and cystic cavity, with the evil conse-
quences thereof, could be avoided. The use of the aspirator chiefly as a
diagnostic agent has accordingly become universal in doubtful cases. But
of late years the cases have slowly and steadily multiplied, in which even
aspiration has been followed, with a rapidity indicating the relation of
cause and effect, by inflammation of the peritoneum and cyst, and often
decomposition of the contents of the latter, usually terminating fatally,
unless cured by speedy removal of the cyst. The size of the aspirator
needle seems to be of comparatively slight moment, for one case is reported
in which peritonitis followed the now very common, and usually harmless,
diagnostic removal of a hypodermic syringeful of fluid. At a meeting of
the New York Obstetrical Society, held May 18, 1875, Dr. Peaslee said
that a polycyst should never be tapped unless the operator is prepared to
perform ovariotomy within twent}r-four hours ; that in a case, on which
he proposed operating on the following day, inflammation of the cyst fol-
lowed aspiration within forty-eight hours, and that he does not think the
aspirator essentially safer than the trocar, which latter is really to be pre-
ferred as permitting a more rapid egress to the fluid. In a note to me,
dated October 5, 1877, Dr. Peaslee further says, " I have never had peri-
tonitis after tapping or aspirating a monocyst or oligocyst. It is common
in case of poly cysts, i. e., inflammation of the cyst is so, occurring in at
least one-quarter of the cases, and this finally extends to the peritoneum,
and ends fatally."
Under the same date, Dr. Washington L. Atlee writes me as follows :
" I have known peritonitis to follow partial aspiration, but never a com-
plete emptying of an ovarian cyst. I think it dangerous practice, either
in aspirating or tapping, to allow fluid to remain in a cyst capable of
leaking."
Dr. A. M. Fauntleroy, of Staunton, Va., reports1 a case where local
peritonitis and adhesions followed a diagnostic puncture with the hypoder-
mic needle. Ovariotomy was performed, but the patient died from emesis
and diarrhoea.
D. Peruzzi, of Florence, Italy, describes a case3 in which inflamma-
tion of the cyst and decomposition of its contents and septicemic fever
followed the puncture of the cyst on the same day. The patient was
saved by ovariotomy during the fever.
Dr. James L. Little, of NewT York, informs me that he had a case in
1 Transactions Virginia Med. Soc, 1875,
2 Raccoglitcre Medico, Sept. 1875.
1878.]
M unde, Ovariotomy during Peritonitis.
105
which the cyst was twice aspirated for the purpose of diagnosis. Within
forty-eight hours of the second aspiration symptoms of peritonitis set in.
Ovariotomy was at once performed, during which the cyst was accidentally
ruptured by traction on a thick adhesion. A portion of the decomposed
fluid, which was so excessively offensive as to necessitate the opening of
the windows of the apartment, escaped into the peritoneal cavity. It was,
of course, carefully cleansed, but the patient died of collapse in twelve
hours.
Dr. TTilliam Goodell, of Philadelphia, at the recent meeting of the
American Gynaecological Society, at Boston, in May, 1877, reported a case
where aspiration was rapidly followed by inflammation of the cyst and de-
composition of its contents. Formidable septic symptoms set in, and he
was forced without delay to operate, removing the cyst per vaginam. The
patient recovered. Basing the statement on this case and others (all of
which are included in this list) Dr. Goodell said that aspiration of an
ovarian cyst is never free from danger, and that a polycyst should never be
tapped.1
Dr. Joseph Schnetter, of New York, has kindly handed me the notes of
a case in his practice in which electro-puncture had been performed with-
out permanent benefit a number of times. A rapid increase of the tumour
rendered the evacuation of the fluid desirable. This was done by an aspi-
rator. Although no symptoms of inflammation are reported as following
the operation, ten days later Dr. Schnetter, being sent for, found a develop-
ment of gas in the cyst (indicating decomposition of its contents) and
great collapse. He advised immediate ovariotomy, but on the way to the
hospital the cyst burst into the peritoneal cavity, and the patient arrived
at her destination in a moribund condition, and died the next day.
At the meeting of the New York Obstetrical Society, held June 5, 1877,
Dr. William T. Lusk reported two cases, in which aspiration of the cyst
was followed by rapidly fatal peritonitis within forty-eight hours. Besides
the nine cases here mentioned, there have doubtless been others, which
have either not been reported, or if published could readily be found by
searching the literature of the past few years. Indeed, judging from Dr.
Peaslee's statement, above quoted, inflammation of the cyst with conse-
quent peritonitis after aspiration must be a very common occurrence, much
more common, I believe, than the majority of the profession are aware.
At all events, experience renders it tolerably evident that the less an
ovarian cyst is punctured and interfered with before the radical operation the
better, and that aspiration, at least with a regular aspirator needle, should
be performed only when indispensably necessary to the diagnosis, and when
the fluid will not flow through the canula of an ordinary hypodermic
syringe. The latter I should always employ for diagnostic purposes, if
1 Abstract of Proc. of Am. Gyn. Soc, Amer. Journ. Obst., Oct. 1877.
106
Munde, Ovariotomy during Peritonitis.
possible ; and in cases where it is necessary to evacuate the contents of the
cyst to give immediate relief until ovariotomy can be decided upon and
prepared for, or to permit diagnostic examination in a doubtful case, I
should prefer the old trocar and canula as more convenient, and (according
to Peaslee) no more dangerous than the aspirator. In any case, hypoder-
mic syringe, aspirator, or trocar, I should be prepared, cceteris paribus,
to perform ovariotomy on the slightest symptom of septic inflammatory
reaction, provided, of course, the patient wishes to take the only chance
left her for life.
2. Hie Performance of Ovariotomy during the Existence of Perito-
nitis and Oophoro-cystitis — Formerly it would have been thought simply
murderous to admit air to an inflamed peritoneal cavity. But in the year
1865, Keith, of Edinburgh, followed the dictates of common sense and
sound reasoning, which indicated the removal of the exciting cause of the
septic inflammation, and performed ovariotomy in a case where peritonitis
and inflammation of the cyst, following seven days after tapping, had
apparently doomed the patient. Fortunately for the future of the indica-
tion, he was successful, and proved the correctness of the principle by
saving his patient.1 Veit, of Bonn, followed his example in 1867, but did
not succeed in saving the case.2 W. A. Freund, of Breslau, appears to
have been the next to undertake this operation, for on May 13, 1871, he
removed an inflamed multilocular tumour from a patient with subacute
peritonitis (also succeeding tapping), and saved the patient. Another case
soon presented itself to him, in which decomposition of the cyst contents
and excessive distention of the cyst by air, with general septic fever, rapidly
followed tapping ; ovariotomy was quickly decided upon as a last resort —
performed May 19, 1872, and in twenty-one days the patient left her bed
well.3
Including the instance already quoted, Keith has operated on fourteen
such cases, taking the lead of all other operators in this respect, as he does
also in his ratio of successes, which surpasses even that of Spencer TVells,
who, however, far exceeds Keith in numbers. The last case of ovario-
tomy during septic peritonitis, performed by Keith, was a most desperate
one, and shows under what unfavorable circumstances recovery may take
place.4
On the morning of the proposed ovariotomy the cyst burst; aspiration -was
performed. The temperature rapidly rose to 105° F., the pulse to 130 ; vomit-
ing and pain, urine albuminous, lips black and dry. This state of things lasted
ten days, the temperature varying between 103° and 105°. Notwithstanding the
apparent hopelessness of the case, ovariotomy was performed, and the gangrenous,
excessively fetid cyst and contents removed. The intestines were bathed in putrid
lymph, and were adherent to each other and the cyst. The peritoneal cavity was
washed out with a solution of carbolic acid, a drainage tube introduced, and the
1 Lancet, July 8, 1865. 2 Diseases of the Female Sexual Organs, 1876.
3 Berlin Beitr. zur GeburtsLUlfe, vol. ii., 1873.
4 Lancet, March, 1877.
1878.]
Munde, Ovariotomy daring Peritonitis.
107
wound closed by wire sutures. Although the vomiting continued for two days,
the temperature then fell to 100°, and the patient gradually improved, and was
discharged well three months after the operation.
One case only of this kind has occurred to Dr. Thomas, so far as I am
aware (the patient recovered) ; two to Dr. Emmet1 (both recovered) ; six
to Dr. Peaslee (five recovered) ;2 three to Spencer Wells, one to Teale;
one each by Peruzzi, Goodell, and Little, have already been alluded to.
Dr. Atlee informs me3 that he recently had two cases of ovariotomy fol-
lowing rupture of cysts and severe peritonitis ; both cysts were multilo-
cular, and the operation was performed several days after the accident,
when the patients were under great prostration ; both tumours were every-
where adherent by coagulable lymph, and were carefully and readily shelled
off, leaving it adherent to the viscera. Both patients made a good recovery.
Dr. Atlee says, that, " when possible, he would advise an immediate opera-
tion after the rupture of the cyst." This list of Dr. Atlee's cases is un-
fortunately not complete, as his departure from home prevented his answer-
ing my queries as fully as I could have wished. Dr. Gilman Kimball, of
Lowell, Mass., writes me, October 11, 1877 : " In regard to my cases of
ovariotomy, in which peritonitis was found present at the time of opera-
tion, I find it very difficult to speak as definitely as I could wish. The
special point in question would require an examination of my entire
record of cases, now numbering 221. I can, therefore, only speak of
those which come to me on reflection. So far as I can now recollect, I
have never operated where I was satisfied of the presence of what might
be strictly termed acute peritonitis, except in a single instance. In that
case there was a thick layer of recently formed lymph over the entire
front of a very large multilocular tumour, but not affecting the peritoneal
covering of the intestines. In some ten or twelve instances I have met
with evidences of chronic peritonitis, incident, as I suppose, to the exist-
ence of ovarian disease. This condition has been particularly marked in
those cases where there had been a rupture of one or more cysts previous
to operation ; and then again in cases of 'peritoneal effusion connected
with ovarian disease. I have noticed in some half-dozen instances masses
of lymph floating in the serum. It is perhaps worthy of remark, that I
have never seen a case of peritonitis, recent or chronic, where the tumour
consisted of a single cyst. The disease has always been polycystic, and
made up, in part at least, of solid matter. As for results, I cannot state
exactly how the record stands. I can safely say, however, that at least
one-third of the cases with peritonitis have recovered ; this was the fact
with the cases of acute peritonitis above referred to."
Besides these thirty -five cases, doubtless others have been performed
during the past few years, certainly sufficient in number and satisfactory
1 Thomas, Diseases of Women, 1874, pp. 676, whence the cases of Wells and Teale
are also taken.
3 Private letter, above mentioned. 3 Ibid.
108
MuNDfi, Ovariotomy during Peritonitis.
[Jan.
enough, as regards ratio of recoveries (32 out of 35) to confirm the indi-
cation beyond the shadow of a doubt. The universally accepted opinion
of ovariotomists now is that the only chance for life offered a patient
with septic fever depending on inflammation of the cyst or suppuration
of its contents, complicated by acute or subacute peritonitis or not, is to
remove the cyst as rapidly as possible. The physician who hesitates to
do so is, in my opinion, derelict in his duty.
My great regret is that, new as this accident was to me in my ovarian
experience, I did not operate within a day or two after the febrile and
septic symptoms became manifest, instead of waiting over a week. Possi-
bly the patient might then have escaped the fatal septicaemia.
3. The Influence of the Nitrite of Amyl in Counteracting the Depress-
ing Effects of Ether during Ancesthesia, by Stimulating the Heart's
Action Based on the property claimed for the then newly discovered
nitrite of amyl of stimulating cardiac activity by paralyzing the vaso-
motor system, and, consequently, charging the brain with blood, the idea
occurred to me to take the remedy with me, and to use it in case the, as I
knew, exceedingly feeble pulse should flag during the operation. As I
have already stated, the beneficial effects in stimulating the heart, and thus
permitting the continued administration of ether, were witnessed by all
present, and are unquestionable.
While not using the agent in this case specially to counteract the depress-
ing influence of a long anaesthesia, it undoubtedly did act also in this
manner, and I thus unwittingly fell upon a plan as regards ether, which
was suggested a year later1 by Dr. F. A. Burrall, of New York, with
reference to syncope from chloroform. Two cases of resuscitation from
chloroform syncope by amyl-nitrite have lately been reported by Dr.
Pilcher in his Report on Croup and Diphtheria, and very recently2 I find
a case published in which the inhalation of the nitrite of amyl, which,
fortunately, was at hand, according to the testimony of physicians present,
revived the patient from the sudden chloroform collapse, and saved her
life.
I have since adopted the precaution of always carrying a vial of nitrite
of amyl with me when I go to administer chloroform or ether, and it cer-
tainly is a practice which I should recommend others to follow.
1 New York Med. Journ., Nov. 1876.
3 Brit. Med. Journ., Aug. 18, 1877.
1878.]
Kellogg, Melancholies and Suicides.
109
Article VIII.
On the Duties and Responsibilities of General Practitioners to-
wards Melancholics and Suicides. By A. O. Kellogg, M.D., of the
Hudson River State Hospital, Poughkeepsie, New York.
That condition of mind, whether it be of desperation or disease, sanity
or insanity, which leads an individual to the commission of self-murder is
one which most assuredly calls for the careful consideration, not only of
the medical jurist, the moralist, and psychologist, but the general practi-
tioner of medicine, under whose observation, if before it is too late these
cases come under any useful observation at all, they are most apt first to
fall.
No class of patients are more embarrassing to the general practitioner
than those cases of mild incipient melancholia with depressing delusions
and suicidal tendencies. Even in an institution where every means of
guarding and observing them is had, they give more trouble and are a
greater source of anxiety than any other. They can never be trusted,
their mental acuteness, their cunning, and, to the superficial observer,
their apparent sanity, serve to put the physician, as well as attendants and
friends, off guard ; and their faithful promises of self-control are apt to be
relied upon, till some fine morning or calm evening a case of cut throat,
drowning, pistol-shot, poisoning, or strangulation is presented to our horri-
fied gaze, a family is thrown into deep distress, a whole community, pro-
foundly shocked, sympathizes with them, and, as a rule, blindly blames
the doctor.
One of the most serious difficulties the general practitioner has to contend
with in all these cases in their incipiency, is the concealment of grave
symptoms by the family. People have yet to be educated up to the
thought of looking at these symptoms of unusual depression, which lead to
such untoward results, as they would upon any other symptoms of disease.
Sleeplessness, loss of appetite, and general malaise they are ready to meet,
but as soon as the patient passes into the next stage of his malady and
ventilates delusions of a dangerous character — such as the fear of poverty,
disgrace, eternal damnation, etc., and shows a disposition to act on them
to the great danger of himself or members of his family, all is concealment,
and these things are scarcely mentioned, even to the physician, for fear of
publicity and disgrace ; while, at the same time, they hold him responsible
for the safety and treatment of their friends. No one knows better than
a physician placed in my circumstances how strong is this feeling, and
how even we are sometimes troubled to get at all the facts of the case.
Until the public can be taught to face all these grave mental symptoms
and lay them before their medical advisers as fully as they would any
physical symptoms in other diseases, they must be prepared to take the
110
Kellogg, Melancholies and Suicides.
[Jan.
consequences of withholding them ; for the physician cannot be made the
scapegoat in all cases, though perhaps in some he is led to yield feebly to
the prejudices of his patrons, or, as I have known, to motives of a baser
character, until culpability follows from the neglect of a grave responsi-
bility.
So unwilling are friends to act efficiently upon the earlier symptoms of
this grave malady (for indeed it is a grave malady, even in the sense in
which the term is used by Mercutio when the hole through his body,
though not as large as a church-door, Avas sufficient to make him a grave
man) that the earliest evidences are not apt to come under the observation
of physicians in my position ; sometimes, creditably to the intelligence of
friends, and generally fortunate for the patients, I may say, without either
arrogance or egotism, they do come before us promptly.
These early symptoms are the ones to which I desire especially to direct
attention at this time — symptoms which are often neglected too long,
sometimes for years, without any untoward results, but in the end often
most unhappy in their termination. As I penned this paragraph I took
up the morning paper, and almost the first line which met my eye illus-
trates this remark.
"Mrs. Daniel Kunziman cut her throat fatally, early yesterday morning, with
a razor. Since the death of her two children* two years since, she has been
mentally depressed."
Scarcely a paper can be opened that does not contain some similar
announcement. Here the symptoms had lasted for two years, and no
notice appears to have been taken of them.1 Now another great difficulty
to the general practitioner lies in the fact that these earlier symptoms are
not apparently so grave as to call for any special attention ; the delusions,
if developed, are carefully concealed by the patient, and there is nothing
to the superficial observer on which insanity can be so certainly predicated
as to call for treatment, much less for seclusion or restraint. Still, as in
all diseases, there are premonitory symptoms which should be carefully
watched and met, and these I now proceed to point out.
Frequently the patient himself is conscious that there is something
wrong with him, and sometimes he will mention symptoms of a change in
character, conduct, disposition, or feeling, which even his friends, if they
observe them, are not willing to point out, or feel a delicacy in doing so.
He sleeps badly, has disturbing dreams, perhaps, and is up wandering
about his room. His digestion is bad, breath foul, and bowels constipated.
1 The New York Herald of the 7th inst. reports thirteen suicides and nine cases of
drowning, termed accidental, as occurring in the month of May last. This is equal to
the palmiest days of suicidal Paris, when bodies were fished out of the Seine, or picked
up at the foot of the Column Vendome, every morning. Many of these suicides were,
no doubt, the direct offspring of want and desperation ; others, probably, from estab-
lished melancholia resulting from the same. In either case, whether the cause was
direct or indirect, remote or immediate, the result was equally sad.
1878.]
Kellogg, Melancholies and Suicides.
Ill
The usual scapegoats for all physical and mental evils, the stomach and
liver, are charged with not doing their duty, or doing it imperfectly ;
there is great listlessness, torpor of the functions of the brain and nervous
system, thought and feeling, which tprpor may be followed in time by
exaltation of the same faculties — periods of depression alternating with
periods of exaltation.
Now it is in this state that medical treatment is demanded and in which
it tells best, and if it is neglected, the headache usually present becomes
more aggravated, the sleep more and more disturbed, and the patient goes
on from bad to worse, till he passes into the next or delusional stage.
In this first stage, though he may have made neither threats nor
attempts at suicide, he is very uncertain, and should be watched as well
as treated, for at any time he may lose self-control and destroy himself.
It is scarcely necessary for me to point out the indications of treatment
to a society of experienced medical gentlemen, as such will readily suggest
themselves.
The general health must be looked after, digestion and sleep must be
attended to, especially the latter, for if it becomes less and less" the patient
is sure to go on from bad to worse. To accomplish this I use various
remedies, and in various combinations as seem to be indicated by the
individual case. Among these I will mention the following, giving them
in the order in which we have found them most useful : 1st. hydrate of
chloral, in doses of from 10 to 60 grs. ; tincture of hyoscyamus, made from
Squibb's extract, from 5j to 5iij ; officinal solution of morphia, from 5j to
5iij. Each of these remedies will do well in combination writh the others,
in the doses of each spoken of, and will generally accomplish the purpose
and procure from two to six hours of good, natural sleep, when the dose
may be safely repeated. I have yet to see any evil consequences result
from the combination of any two of these remedies in the doses above
indicated. The hydrate of chloral in combination with tincture of hyos-
cyamus is, according to our experience, the best in a large majority of
cases. Opium is not tolerated in many cases of this as of other diseases,
and will aggravate the very symptoms it is given to relieve, and produce
insomnia. Still, there are cases in which morphia, in combination with
hyoscyamus, acts admirably.
We must not fail to look closely after the causes of all these symptoms
and seek to remove them. In a very large majority of cases overwork
and exhaustion from innutrition, or, in women, exhaustion from lactation,
will be found, and these must be remedied. Other causes will oftentimes
be adduced by friends, which, on close examination, it will be found have
not been operative, but others that have been will be readily traced. The
cause, indeed, may have passed away before the case is seen, as frequently
happens ; but its effect upon the brain will still have to be dealt with, and
this is sometimes very lasting, and will require much time for its removal
112
Kellogg, Melancholies and Suicides.
[Jan.
and much patience on the part of both friends and physician. Frequently,
however, by the judicious management of this early stage much will be
done towards preventing the evils of a more advanced condition. In
nearly all cases there should be some change in the external circumstances
of the patient, and here many things must be taken into account.
One of the first means proposed is to attempt to divert the patient's
morbid thoughts from himself by travel; but, according to my experience,
this is of little use, for the patients take their diseases with them, and
though they take their physicians along, time must do the work, while the
physician must do the watching, and this latter duty is not by any means
as easy as the simple prescribing of drugs. If lie travels by rail the
physician is constantly harassed by the thought that every comfortable
drawing-room car may at any moment become a car of Juggernaut to his
patient ; and if he travels by steamship, the temptation to sea-bathing
from the stern of the ship is, as in the case of a late judge of the Supreme
Court of this State, too great for the resistance of the patient or the
vigilance of the physician.
A trip of any kind, except to a hospital, in the early stages of melan-
cholia, as in all other diseases, is worse than useless, a delusion, and a
snare, however useful such may be in promoting convalescence when this
is once fairly established. Melancholia, like every other disease, in its
early stages requires rest, care, and treatment, and wherever these can be
best secured is the place for the patient.
Wherever he is, he must be carefully nourished and sustained by a full
generous diet. From fear of biliousness or indigestion, he has probably
fasted, abstained from food at least, and perhaps from drink ; but as to
the last it is not improbable that he may have indulged excessively in
stimulating beverages. These in moderation, however, are not without
their use, for in all such cases there is generally deficiency of nerve and
brain force, which, next to good nutritious food, is supplied by wine, eggs,
milk, malt liquors, iron, quinine, strychnine, arsenic, etc., as, in the judg-
ment of the physician, may seem indicated. But in spite of all your
efforts, all your care, nutrition, medication, and watchfulness, the case, as
often happens, goes on from bad to worse. Most extraordinary delusions
arise, and prompted by these delusions we witness the most extraordinary
conduct, and acts, often most ludicrous, sometimes dangerous, always
painful to the truly humane observer, however amusing they be to the
thoughtless and impertinent, from whose observation they should be care-
fully guarded. Delusions, as we have said, of a most painful character
take full possession of the mind. A poor woman now under my care
refuses food, under the delusion that it is prepared from the bodies of her
children, who are all dead, and she has had to be nourished with the
stomach tube. A highly intelligent, educated, and wealthy gentleman,
now under my care, under the delusion that his family are down in the
1878.]
Kellogg, Melancholies and Suicides,
113
Water-closet, refuses to pass his motions there, and soils his clothing, his
room, and even the hall where others are, if not watched closely. He is
unwilling to take food because he is too poor, and because he thinks doing
so will bring his family to want. »
The other day I stood by while an attendant was patiently urging him
to take a glass of milk punch. He looked at me piteously and asked to
be excused from drinking, as the drouth was already so great that the
world was being burned up, and for him to drink anything would do him
no good, but only hasten the catastrophe.
A medical gentleman, once of some local eminence in New York City,
now a melancholic under my care, maintains that he is burned to a cin-
der, and will hold out his hand to you and insist that it is " cremated. "
His clothing, like the fiery shirt of Nessus, burns him so dreadfully at
times that even in the coldest winter weather he will strip himself entirely
nude. At other times, though he is never entirely free from his dreadful
delusion, he is more comfortable, and then he will make as correct a diag-
nosis, and as judicious a prescription for a fellow-patient in the ward, as
any sane physician. He also perceives the ridiculousness of the delusions
of others, and will comment upon, and sometimes laugh at them, without
the power to recognize his own.
Another gentleman, of many polite accomplishments, bears in his fore-
head the scar of the pistol ball with which, in a moment of utter despera-
tion and depression, incident to melancholia, he sought to escape from the
world and its sorrows and perplexities. During much of the time this
gentleman is comparatively comfortable, though never cheerful. One
peculiarity of his case, which contributes much to his safety, and lessens
greatly our anxiety respecting his care, is that he knows well when one
of his paroxysms is approaching, and will warn us, if we have not already
perceived it, that we may place him under closer surveillance, and even
in mechanical restraint if it is deemed advisable.
Such are the characteristics of a few cases now under my observation.
I might go on multiplying them from memory, but those given suffice for
my present purpose.
Some melancholies are so life-weary, and, without any special delusions,
perhaps, are so depressed in spirit, and like Hamlet take such gloomy
views of the world and all that it contains, that they sigh constantly and
seek continually to be ont of it and at rest. How they get out of it they
care not, and what they may possibly encounter in that " undiscovered
country from whose bourne no traveller returns" has no terrors weighed
in the balance with their present misery.
" Oh let me die," said a poor woman once to me, " in any way. I care
not how ; put me in the furnace if you see fit," and I certainly believe,
from the desperation of her attempts, she would have plunged in the flames
if allowed. Another, similarly affected, concealed matches, and retiring-
No. CXLIX Jan. 1878. 8
114- Connor, Reproduction of the Membrana Tympani. [Jan.
to rest, set herself and bed on fire, and was fatally burned. I believe a
similar case occurred not long since in the city of Poughkeepsie, though I
am not acquainted with the particulars.
And now I ask, in conclusion, what are general practitioners to do with
such cases ? I speak now as one who has been in general practice, and
my answer is, they must be placed at once, and as quietly as possible, in
some hospital devoted to such diseases.
The only conditions under which I would assume the care and responsi-
bility of such outside of an asylum, can scarcely ever be had. If we could
convert their homes even into a maison de sante, send away the family, the
most perplexing element to which we or they can be subjected, have in their
place a sufficient relay of experienced attendants that could be held to a
strict accountability for the life and well-being of the patient, even then
I should doubt my ability to care for them as they should be. I should
certainly hesitate, in view of some experience I have had in their care,
even under such circumstances. It is quite enough to assume the respon-
sibility, care, and treatment of such cases when we are furnished with all
the appliances and means which the science and Christian humanity of
modern times has placed at our disposal.
Article IX.
Acute Inflammation of the Middle Ear; Destruction and Repro-
duction of the Entire Membrana Tympani. By Leartus Connor,
M.D., Professor of Physiology and Clinical Medicine in Detroit Medical
College.
On Saturday, April 14, 1877, I was called to see Mr. Jas. D. for an
intense pain in his right ear. Mr. D. was a resident of Detroit, forty-two
years old, English by birth, a bricklayer and builder by trade, of nervo-
sanguine temperament, married for ten years, the father of three children,
an enthusiastic, industrious worker, and temperate in all his habits.
I found the patient lying in bed, giving every evidence of extreme suf-
fering. On inquiry I found that about eight days before the date of my
visit he was taken with a severe cold, sore throat, swollen tonsils, headache,
and slight febrile disturbance. These symptoms gradually increased until
on Tuesday last, when there was added to them a pain in the right ear.
This pain increased daily, and was attended by great throbbing of the
right side of the head ; a hyperesthesia of skin covering these parts, and
neuralgic pains in various branches of the fifth nerve. All this time he
had been going out and attending to his business. On Thursday, two days
before I saw him, he became alarmed, and sent for his family physician,
Dr. E. W. Jenks. He, finding a severe tonsillitis and pharyngitis, pre-
scribed accordingly. The following day, on his own prescription, the
patient applied a hot poultice to his ear, but obtained no relief. Dr. Jenks
being ill, this day, the patient was seen by Dr. Geo. P. Andrews. On
1878.] Connor, Reproduction of the Membrana Tympani. 115
Saturday, being convinced that there was trouble in the middle ear. Dr.
Andrews called me to take charge of the patient.
On physical examination I found the nares almost occluded by the swollen
mucous membranes. The tonsils were enlarged, especially the right one,
and with the elongated swollen uvula *they obstructed both respiration and
deglutition to a considerable extent.
The entire right auricle was sensitive to the touch, and somewhat swollen.
Below and posterior to the auricle, but in close connection with it, there
was a spot exquisitely painful to touch or to any movement of the auricle.
There was no tenderness of the mastoid process aside from that of the
skin. Any pressure upon the tragus, or just anterior to it, caused the
patient to cry out. Using a large concave mirror attached to my forehead
and aural specula, I found the external auditory canal swollen, red, and
tender. After some difficulty I succeeded in getting a good view of the
membrana tympani. It had a peculiar slimy, soggy, distended, and dead
look. There was no sign of the handle or head of the malleus. Despite
the greatest care during the necessary examination, the use of the specula
caused much pain.
No outside sound could be heard by the affected ear, not even the tick
of a watch in contact with the ear.
Patient complained of shrill, loud, whistling, and buzzing sounds in his
right ear, and he likened them to the escaping steam from a dozen steam
engines. My diagnosis was acute otitis media.
Leeches failing to afford relief when applied near the tragus, I used a
warm water douche. Some considerable benefit from this was observed by
the patient. In a few moments, however, there appeared in the receptacle
for the water which came from the ear, an ovoid-shaped disk, having
diameters apparently similar to those of the inner extremity of the audi-
tory canal. Dropping the douching apparatus I at once examined this
disk. It was perfectly smooth on both sides, except for a little space about
as long and broad as the handle and head of the malleus. The edges
were very regular, almost as if it had been cut by a punch. Its thickness
was quite uniform, and as I estimated between one and two lines. A re-
examination of the ear with mirror and speculum enabled me to see the
ossicles in place, surrounded by the inflamed lining of the middle ear. The
most careful scrutiny at this and many other times during the next two
weeks, failed to detect a particle of the drum remaining in the ear.
I informed the friends that the drum of Mr. D.'s ear was completely
destroyed, that the walls of the middle ear, the Eustachian tube, pharynx
and nares were involved in a severe inflammation, that he would probably
recover, but that the drum would not be restored nor much of his power
of hearing.
I left directions for the use of the hot water douche every two or three
hours, as needed for the pain ; also a mixture of opium and bromide of
sodium.
On my way home I called at Dr. Jenks's office, and exhibited to him the
necrosed membrana tympani, pointing out its peculiar shape, its swollen
and soggy condition. That I did not preserve the drum was due to the
fact that I saw no reason for so doing. No case had ever fallen under my
observation or reading that had terminated other than as I had indicated
in my prognosis.
For the next six weeks I saw the patient two or three times each day.
The pains in his head, or deep in his ear, were of such intensity that dur-
116 Connor, Reproduction of the Membrana Tympani. [Jan.
ing the first month I was unable to control them so as to produce a com-
fortable sleep. Narcotics alone or in combination seemed to do more harm
than good. Hydrobromic acid was of great and positive service in pro-
ducing an endurable quiet, and especially in alleviating the various whist-
ling and ringing sounds. It was given in drachm doses every two to six
hours as needed. As a nerve tonic quinia bromide was administered
quite freely. Every care was taken to sustain the general strength, and
to promote the most perfect nutrition, general as well as local. At no
time was there any considerable discharge of pus. The swelling of the
throat, Eustachian tubes, and nares gradually subsided, so that air passed
readily out of the ear each time the nostrils were blowed, and the douche
of water passed through the ear into the throat and nares. The severity
of pain and irritation of the auditory nerve continued with but little abate-
ment till May 16th.
The details of my daily observations for the first six weeks have no
special importance, hence I will merely give the state of my patient at a
few separate intervals.
May 16. Found him decidedly better. The escaping-steam sounds
were less. Loud voices could be distinguished, but not the ticking of a
watch. Air passes less readily through the ear on blowing the nose, and
water no longer runs into the throat when the ear is douched. Careful
examination, with the head mirror and ear speculum, shows a vascular
projection around the entire auditory canal exactly at the site of the former
membrana tympani. The projection was greatest at the bottom of the audi-
tory canal, and gradually diminished to the horizontal diameter, the upper
portion being nearly uniform. The first appearance of this growth was
noticed two weeks anterior to this date. On May 26th the entire opening-
was closed, and the external ear perfectly separated from the middle.
Through the speculum this new growth appeared red and shining. On
blowing his nose the patient says that the sensation is identical to that in
the unaffected ear. For the first time he hears a watch, but not more than
an inch from the ear. He now goes down stairs to meals, and occasionally
drives out. His appetite has returned, and other functions arp normal.
June 15. Examination of the drum revealed marked changes in its lower
and anterior third, so that this portion closely resembled the normal drum
membrane. The remaining portions of the drum are still vascular, and
there is no sign of the handle or head of the malleus. Ordinary conver-
sation is heard, the patient states, as well as ever, and even whispering, but
by the watch hearing is only
SOth. The head of the malleus was distinctly seen, also patches of clear
membrane, mingled with red, throughout the upper and posterior portions
of drum. Watch can now be heard at 52g.
August 25. The redness of the membrana tympani has all disappeared.
There is one considerable opacity in the lower and anterior segment, but
otherwise the drum membrane very closely resembles that in the sound
ear. The Eustachian tube is open, and its inflation causes the usual move-
ments of the membrana tympani. Watch can now be heard at ?4^.
94 Cass St., Detroit, Mich.
1878.]
Bi&elow, Lithotrity by a Single Operation.
117
Article X.
LlTHOTRITY BY A SlNGLE OPERATION. By HENRY J. BlGELOAV, M.D., PrO-
fessor of Surgery in Harvard University, and Surgeon to the Massachusetts
General Hospital.
When Sydney Smith asked, "What human plan, device, or invention
two hundred and seventy years old does not require reconsideration?" he
would no douot have regarded with favour an occasional reconsideration of
the theory and practice of medicine and surgery — especially in view of the
current belief, that their traditions have been kept alive and their rules
prescribed in part by authority. The surgical literature of lithotomy,
both French and English, so long showed the influence of the early spe-
cialists, that we have hardly now escaped from its exaggerated circum-
stance and detail. And yet, with attention to a few precise rules, the
operation of lithotomy is quite a simple one — much less difficult, for
example, than the dissection of tumours. It is not impossible that con-
victions in some degree traditionary may prevail in regard to certain
points connected with the practice of the more recent art of lithotrity.
Civiale was among the first to inculcate the excessive susceptibility of
the bladder under instruments. Later surgeons, perhups influenced in
part by his teaching, have continued to invest the operation of lithotrity
with precautions, which, though by no means groundless, because under
certain conditions both the bladder and the urethra are actively resentful
of even slight interference, are nevertheless greater than this operation
generally requires. As a rule, there is little difficulty in it. The stone is
readily caught and broken into fragments, of which a few are pulverized ;
a large-eyed catheter is then sometimes introduced; a little sand and a
few fragments of stone are washed out ; after which the patient is kept
quiet to discharge the remainder, and await another " sitting." Under
favourable circumstances, such an operation, lasting a few minutes, is not
only simple, but safe. Yet the fact that it is not always so could not fail
to arrest the attention of surgeons. It may happen that during the suc-
ceeding night the patient has a chill : not the chill of so-called " urethral
fever," which sometimes follows the mere passage of a bougie, and which
is of little consequence ; but one accompanied or followed by other symp-
toms, such as tenderness of the region of the bladder, a quickened pulse,
and the frequent and painful passage of urine. These symptoms may
insidiously persist, rather than abate ; others may supervene. The surgeon
vainly waits for a favourable moment to repeat his operation ; it becomes
too evident that the patient is seriously ill, and it is quite within the
range of possibilities that in the course of days or weeks he may quietly
succumb. An autopsy discloses a variety of lesions ; some of them remote
or obscure, others of more obvious origin ; and among these, not the least
common, an inflamed bladder, upon the floor of which angular fragments
118
B i g e l o w , Lithotrity by a Single Operation.
[Jan.
and chips of stone are resting. It is then evident that during a certain
interval before death the bladder was not in condition for further instru-
mental interference ; and although, in view of the fatal result of delay,
lithotomy or active lithotrity, to both of which in cases like this 1 have
resorted, might have been on the whole the least of evils, it is plain that
either operation would have furnished in itself an additional cause of
serious inflammation.
Such a result might be supposed to point to the necessity of extreme
precaution ; and it will be justly urged that the purpose of such interfe-
rence at an unfavourable moment is the removal of the offending fragments
as a last resource. But if at the first operation the bladder could have
been completely disembarrassed of every particle of stone, even with the
risk of irritating its lining membrane, we can hardly doubt that the relief
would then have been followed by ready repair. In short, it is difficult to
avoid the conviction, that, in an average case, damage to the mucous
membrane, and quite as great, is as likely to follow the persistent irritation
of angular fragments as the protracted use of instruments for the entire
removal of a stone, provided only this can be accomplished.
It is probable that the injury from the use of instruments has been in
some measure confounded with that resulting from the presence of frag-
ments in the bladder. That the average bladder and urethra have no
extreme susceptibility is attested by the generally favourable results of
lithotrity, and even of catheterism, which are practised with very varying
skill everywhere ; also by the singularly innocuous results of laceration of
the contracted urethra, by an instrument like that of Voillemier for exam-
ple; so, too, by their recovery from the considerable injury inflicted during
the extraction of a large and rough stone in lithotomy. The bladder is
often also tolerant to an extraordinary degree of the presence even of a
mulberry calculus. When Ave remember that in this case it clasps the
stone at every micturition, often with a persistent gripe, the comparative
immunity of its tender mucous membrane is quite remarkable. But when
sharp fragments are thus embraced, presenting fresh and acute angles,
which do not soon become blunted, and to which the bladder is unaccus-
tomed, it is more remarkable that serious consequences are the exception,
and not the rule, in lithotrity. Polished metallic surfaces carefully ma-
nipulated can hardly do such damage as the agencies here enumerated.
Gentleness, dexterity, and experience are especially to be valued in
lithotrity. It has been wTell said, that no novice should undertake this
operation. But the habit of confounding the symptoms resulting from the
presence of fragments with those following the use of instruments originally
led to precautions in the introduction and manipulation of the latter which
were sometimes excessive. Civiale, with an almost unparalleled experi-
ence, introduced a small lithotrite with much less pressure than its own
weight, and with uniform and great sloAvness. And yet, in a healthy
1878.] Bigelow, Litliotrity by a Single Operation.
119
urethra, it is only at the triangular ligament and beyond it that such ex-
treme care is called for. Civiale, who had no means of evacuating frag-
ments in the bladder, restricted the length of his operation to two or three,
or perhaps five, minutes. The same solicitude seems to have led Sir Henry
Thompson, in his admirable and standard work upon this subject, to assign
two minutes as the proper average duration of a sitting ; a period which his
exceptional skill has often in his own practice enabled him materially to
reduce. I have been gratified to find, however, that since he has availed
himself of the advantage of etherization he recognizes the benefit to be
derived from somewhat more prolonged manipulation. My own conviction
is, that it is better to protract the operation indefinitely in point of time, if
thus the whole stone can be removed without serious injury to the bladder.
I believe, that, in any case which is as favourable to litliotrity as the aver-
age in these days when stones are detected early, this can be effected ; and
that, if the bladder be completely emptied of detritus, we have as little to
apprehend from the fatigue of the organ consequent upon such manipulation
as from the alternative of residual fragments and further operations. The
duration of the sittings in the cases reported at the end of this paper varied
from three-quarters of an hour to three hours and three-quarters. The
bladder can be thus completely and at once evacuated, in a majority ot
cases. The stone, after crushing, can be removed through the urethra by
a tube contrived for the purpose.
But has not this result already been attained by evacuating instruments
variously devised and modified ? The following quotations from the latest
authorities sufficiently answer this question in the negative : —
"~\Ye may here say, without fear of being accused of exaggeration, that evacu-
ating injections practised after sittings of litliotrity have no apology for their use.
The whole surgical arsenal invented for their performance is absolutely useless.
. ... It should be well understood that the best of the evacuating catheters is
worthless." (Article " Lithotritie," by Demarquay et Cousin, in the Nouveau
Dictionnaire de M&decine et de Chirurgie Pratique, Paris, 1875, pp. 693-4.)
"The practice of injecting the bladder to wash out detritus is obsolete
The apparatus of Mr. Clover should not be employed, if it be possible to dis-
pense with it ; as its use is quite as irritating as litliotrity itself." (S. I). Gross,
Diseases, etc., of the Urinary Organs, Philadelphia, 1876, p. 232.)
"Having used it very frequently" (Clover's Apparatus), "I would add that it
is necessary to use all such apparatus with extreme gentleness, and I prefer to do
without it, if possible." (Sir H. Thompson, Practical Litliotrity and Lithotomy,
1871, p. 215.)
ilAll these evacuating catheters are little employed. They require frequent and
long manoeuvres which are not exempt from dangers ; besides, they give passage,
as a rule, only to dust, or to little fragments of stone, which would have escaped
of themselves without inconvenience to the urethra." (Article, "Lithotritie,"
by M. Voillemier, Dictionnaire Encyclopidique des Sciences Med. 1869, p. 733.)
In short, the " evacuating apparatus" hitherto employed does not eva-
cuate.
It is not a recent contrivance. From the earlier days of lithrotrity, the
operation of breaking the stone has been followed by the obvious expedient
of introducing a large and special catheter, through which water was in-
120 Bigelow , Lithotrity by a Single Operation. [Jan.
jected and allowed to escape, bringing away a little sand with a .small frag-
ment or two. This attempt at evacuation was aided by suction. With
this object, and before the year 1846, Sir Philip Crampton employed an
exhausted glass globe. For the same purpose a syringe has been used, or
a rubber enema or hydrocele bottle, with which fluid could be also injected
and the bladder washed. By entering the catheter well within the bottle
or syringe, fragments were dropped inside the neck, where lying below the
current, they were not returned to the bladder when the bottle was again
compressed. When this neck was made of glass by Clover, the fragments
became visible; and to this neat arrangement the accomplished lithoiritist.
Sir Henry Thompson, refers, as Clover's bottle. But neither the previous
practice nor the efficiency of evacuation by suction through a tube had been
materially advanced. In the mean time the syringe was modified in France
by a rack and pinion attached to the piston, so that water could be injected
and withdrawn with great force ; a procedure not only useless, but detri-
mental to the bladder, if it be inflamed and thickened.
Before describing my own instruments, it may be well to say a word in
regard to the introduction of instruments, esj ecially large ones, into the
bladder; an important subject in this connection.
A syringe facilitates an abundant use of oil whether in the urethra or
within a tube. Into the normal urethra a straight instrument can be intro-
duced with at least as much accuracy as a curved one. Either may be
passed rapidly as far as the triangular ligament — unless the instrument is
very large, in which case great care is required not to rupture the mucous
membrane. Having reached this point, which requires that the instrument
should be passed as far as it will go in the general direction of the anus,
the extremity of the instrument depresses the floor of the urethra in front
of the ligament. Traction upon the penis next effaces this depression, and
adds firmness to the urethral walls ; so that if the instrument be withdrawn
a little, and, at the same time, guided by the bony arch above, it can be
coaxed without difficulty through the ligament in question — a natural ob-
struction which physicians often mistake for a stricture. This obstruction
passed, the rest of the canal is short, and corresponds to the axis of the
body. Even the enlarged prostate can often be traversed advantageously
by a straight instrument. In fact, a prostatic catheter, as is well known,
consists mainly of an inch or two of straighter tube added to the extremity
of a common catheter, to reach through the unyielding prostate before the
hand is depressed and the beak turned up. In passing either a sound,
catheter, or lithotrite, the extremity of a straight instrument, and, which
would be less expected, the convexity of a curved one, may be arrested just
at the entrance of the bladder by the firm lower edge of the inner meatus.
The fact that water now passes through the inner meatus thus dilated, or
that a stone is felt with the tip of the curved instrument which has really
entered the bladder, may lead the operator into the mistake of supposing
1878.]
Bigelow, Lithotrity by a Single Operation.
121
that the instrument is fairly in it; and I have known its further entrance,
after sliding over this obstacle, to be erroneously attributed to the existence
of a second, or hourglass cavity, in the bladder itself. To obviate this
difficulty, and so soon as the triangular ligament is passed, the catheter
should be pressed through the indurated neck, or prostate, in the direction
of the axis of the body, with the hand on the perineum ; a most efficient
manoeuvre , when the prostate is large. If there be doubt, the tip should of
course be sought and guided in the rectum. After introduction, a straight
tube, or the shaft of a curved one, returns to an angle of about 45° with
the recumbent body, and, if the patient is not etherized, a feeling of tension
may then be relieved by depressing, with the hand upon the pubes, the
suspensory ligament of the penis; an expedient also useful during the
passage of the instrument.
My own practice has always been to etherize for lithotrity.
Each operator prefers the position to which he is accustomed ; and
when the urethra is healthy, this is of very little importance. But if
there be stricture or prostatic obstruction, a position at the patient's left
side enables the operator to hold and direct the instrument to advantage
with the right hand, leaving the left hand free to act in the perinaeum.
After the instrument is introduced, and both hands are required above
the pubes, they are most available, if the surgeon changes his position and
stands upon the patient's right.
It is well, by a preliminary injection, to ascertain carefully the capacity
of the bladder by emptying it and then refilling- it slowly with warm wa-
ter, previously measured, until the water is expelled through the loosely
held urethra, by the side of the tube. In the etherized subject a short
pipe or nozzle suffices for this purpose. I have for many years employed
a common Davidson's syringe. An unetherized patient may for a mo-
ment resist this injection through a short tube, by contracting the sphinc-
ter of the bladder ; but this readily yields. Except in a large bladder, a
capacity of eight or ten ounces need not be increased. The smaller the
injection, the more readily, indeed, do fragments fall into the blades of
the instrument. But. unfortunately, so also does the mucous membrane.
In fact, with too little fluid in the bladder, the use of a lithotrite in un-
practised hands is attended with danger ; and in a long sitting, an injec-
tion which will render the walls moderately tense is the only really safe
way of keeping the bladder from between the blades. After careful ex-
amination of the action of a lithotrite through an opening in the summit
of the bladder, I have returned to this opinion, which was held by the
older writers on this subject. From time to time the diameter of the col-
lapsing bladder should be estimated by carefully opening the blades of the
lithotrite, and water should be introduced when necessary ; but care
should be taken not to injure a contracted bladder by first distending it,
and afterwards adding to it the contents of the aspirating bottle.
122
Bigelow, Lithotrity by a Single Operation.
[Jan.
Fig. 1.
A tape or an elastic band wound lightly once or twice around the penis
retards the escape of injected water, and yet allows the movements of the
tube or lithotrite.
In order to ascertain the maximum calibre of the urethra, before intro-
ducing a tube, it should be measured by an instrument which will enter
more readily than the tube. Such instruments we have in Van Buren's
sounds, which are slightly curved at the end, and a little conical. Being
made of solid metal, and nickel-plated, they traverse the urethra with sin-
gular facility. Otis's sounds also answer admirably for this purpose.
Evacuating Instrument. (Fig. 1.) — The following points are wor-
thy of consideration in connection with any evacuating apparatus. The
ten-ounce elastic bulb or bottle usually
supplied with such an instrument is
inadequate to the exhaustion for which
it is designed. It will barely sustain,
without collapse, a vertical column of
water of the length of a catheter. A
thicker flask fatigues the hand of the
operator. The bulb is also an awk-
ward weight at the top of the cathe-
ter. These difficulties are obviated
by interposing between the catheter
and bulb two feet of rubber tube,
which relieves the bladder from the
force of any movement of the appa-
ratus, and, what is more important,
allows the operator to hold the bulb
on a level with the water in the blad-
der, or considerably below it. The
exhaust then acts as a siphon, and
readily draws off the water. The
fragments gravitate to the bottom of
the bulb, and may there be collected
in a glass chamber. (See Fig. 1, a.)
To prevent the possible return to the
bladder of some single fragment while
on its way to this receptacle, the rub-
ber tube might be provided writh a
small glass trap containing a wire-
gauze or perforated tube, or valve,
to deliver the current and strain it on
its return.
The successful evacuation of the bladder depends upon several condi-
tions, both in the apparatus and its use, which, for distinctness, may be
enumerated separately.
Evacuating Apparatus, n. Elastic bulb
and glass receptacle with brass cap, for de.
bris. 6. Rubber tube two feet in length., e.
Evacuating tube of silver.
1878.]
Bigelow, Lithotrity by a Single Operation.
123
1. A large calibre of the evacuating tube.
2. Its shape.
3. The shape of its receiving extremity.
4. The assemblage of fragments around this extremity.
5. The immediate recognition and removal of any obstruction in the
tube.
1. A large calibre of the evacuating tube Whether or not we adopt
the view of Otis, that the average capacity of the normal urethra is about
33 of Charriere, there can be no question that it will admit a much larger
tube than that commonly attached to either Clover's or the French appa-
ratus. The efficiency of the process of evacuation depends much upon
using the largest tube the urethra will admit. This fact has been stated
by Sir Henry Thompson. But he recommends for the glass cylinder or
trap which is to admit this tube a "perforation at the end, the size of
a No. 1-1 catheter," = 25 Charriere. (Diseases of the Prostate, 4th
edition, 1873, p. 337.) This perforation is too small; and the tube which
is designed to enter it is further reduced by its collar to the diameter of
only 12, = 21 Charriere. In fact, this is the calibre of the evacuating
catheters now attached to Clover's instrument, and is of itself fatal to their
efficiency. An effective tube has a calibre of 28 to 31 or even 32 Char-
riere, and the meatus, which is the narrowest part, may, if necessary, be
slit to admit it, if the urethra is otherwise capacious. Again, in the in-
strument, as sometimes constructed by Weiss, a joint is made by inserting
an upper tube into a lower one, thus obstructing the calibre by a shoulder.
The joints should become larger as the tube approaches the bottle, and the
tube then delivers without difficulty fragments of its own calibre.
My tubes are of thin silver, of sizes 27, 28, 29, 30, and 31,filiere
Charriere, respectively.
2. Shape of the tube Works upon Lithotrity enumerate and figure a
variety of tubes through which fragments are to be aspirated. Many of
these are useless. The best tube is either straight, or curved quite near
the extremity ; the latter to be used with the curve inverted and directed
downward, the orifice then looking forward. (Fig. 2.)
3. Shape of the receiving extremity The receiving extremity should
depress the bladder, and thus invite the fragments, while its orifice remains
unobstructed by the mucous membrane. A fragment of stone, however
light, if it lies at the distance of a half or even a quarter of an inch from
the tube extremity, is not attracted by the usual exhaust of the expanding
bottle, which requires that the fragment should lie almost in contact with
the tube. A very slight obstacle impedes its entrance ; and this fact
renders inefficient all tubes like catheters, with orifices in the side or upper
wall. Chips will not surmount their edge. Again, the orifice of a tube
cut square is at once occluded by drawing in the vesical wall ; while the
spoon-shaped beak of the French instrument, made like the female blade
124 Bigelott, Litliotrity by a Single Operation. [Jan.
of a lithotrite, allows fragments to lie too far from the opening in the tube.
The best orifice is at the side of the extremity, and is made by bending
the tube at a sharp right angle, carefully rounding the elbow, and then
Fig. 2.
Evacuating Tubes, with unguifjrm extremity, a. Strai ;ht tube. b. Curved tube. The clotted
lines show the inside floor. The tubes are here of a diameter 31 Charriere.
cutting off the bent branch close to the straight tube. (Fig. 2 «.) The
tube is then practically straight ; while its orifice, which is slightly oval,
delivers a stream at an angle with it. The edge should be thickened and
rounded so as to slide smoothly through the urethra, any rim inside the
orifice should be masked by a false floor, but the calibre should be nowhere
contracted. If the side walls of this orifice be removed a little, it gives
an unguiform extremity to the tube, which is advantageous ; and in intro-
ducing such a straight tube, this tip may be gently insinuated through the
triangular ligament by rotation. If a couple of inches of the end of such
a tube be bent, it may be inverted after introduction, and will bury itself
in the floor of the bladder, which it depresses, while the orifice looks for-
ward and is unobstructed. This form is quite efficient. (Fig. 2 b.) An
effective instrument might also be made of a tube cut square at the end,
if a disk convex outwardly, to repel the bladder, were attached to it, at
the distance of a diameter, by a bit of stiif metal. Yf hen such an instru-
ment is introduced, the interval may be filled by a rod. In fact, the orifice
of the tube should be contrived with a view to its introduction. The
French tube already spoken of, shaped like the female blade of a lithotrite,
would be efficient, if it were made large enough — and provided also it
were kept standing upon its heel in the bladder, with a shoe bent to make
a precipitously inclined plane for the fragments. It would then offer a
prolongation of the unguiform tip. But thus sharply bent, it would be
1878.]
Bigelow, Litliotrity by a Single Operation.
125
less easy to introduce. Whatever be added to the extremity of the tube,
in order to facilitate its introduction or to repel the bladder, should not
prevent the orifice from lying in the floor of the bladder at the apex of a
steep inverted tunnel.
4. The assemblage of fragments around the extremity If the orifice
of the tube be now placed among the fragments, it will be found that even
a teaspoonful of water, lightly injected, shoots them to every part of the
bladder, whence suction wholly foils to attract them, unless by chance.
But if the compressed bottle be held motionless four or five seconds, the
fragments gravitate to the lowest part of the bladder at the point where
the extremity of the tube indents it. This artificial depression, which is
made by very slight force, plays an important part both in crushing and
evacuating the fragments. In placing the tube in a bed of fragments be-
fore each aspiration, there is opportunity for a little tact, as in discovering
fragments with a lithotrite. The readiness with which fragments are
thrown to a distance by an almost imperceptible compression of the bottle,
the time required for their gravitation, and the difficulty of attracting them
even at the distance of only a quarter of an inch, will hardly be appreciated
without experiments outside the bladder.
5. The immediate recognition and removal of obstruction in the tube
There is but one usual source of obstruction to the exhaust, namely, too
large a fragment at the orifice ; and then even the powerful rack and
pinion of the French syringe are of no avail. The obvious remedy is to
expel the fragment by compression in the ordinary way. It is therefore
essential to recognize its presence at once. Practically, during the whole
J process, I watch the expanding bottle while the dimple in its side is gra-
dually effaced. If this dimple remains stationary for a moment, I know
that a fragment obstructs the orifice, expel it without loss of time, allow
the fragments to settle, and take my chance for another. With the lateral
orifice described, and enough water to separate the walls of the bladder,
there is little probability of obstruction by drawing in the mucous mem-
brane, so long as the orifice looks upward ; but if the orifice of the straight
tube be rotated sideways, or to face the spine, the bladder at once plugs it.
With^he inverted curved tube, the bladder is less readily engaged.
After a dozen or two aspirations it may be found that all the fragments
which can pass the tube have done so. By the usual method of crushing,
the lithotrite would now again be introduced, and again be followed by
the tube.
Lithotrite (Fig. 3.) — It would be plainly desirable, if it were easy, to
crush the whole stone at once, before attempting to evacuate it ; but this
has hitherto been rarely possible. The lithotrite becomes so choked with
impacted debris that the convex surface of the mass less readily receives
additional fragments. A clean lithotrite always works to best advantage ;
and the operator frequently withdraws the loaded instrument, sometimes
126
B i G e l o w , Lithotrity by a Single Operation.
[Jan.
with injury to the neck of the bladder, to evacuate it. It would be
obviously better, if the instrument could be emptied at will in the bladder
— especially if we distinctly recognize that what can be withdrawn in a
lithotrite would come better through a tube, and that the only province
of the lithotrite should be to pulverize, or indeed merely to comminute,
and not to evacuate.
Although all lithotrites are made a little loose for the
purpose of working out the debris, and although I have
had one constructed with an especial device for this mo-
tion, I do not find it easy to clear the concave blade by
a lateral movement of the male blade, chiefly because the
impaction is so firm, that the dense mass, instead of yield-
ing, twists the female blade from side to side. Nor does
an instrument like that of Reliquet fulfil the indications.
It discharges itself, indeed, as does the old fenestrated
" litlloclast.', But, as in all lithoclasts, its high sides are
an obstacle to the approach of fragments. The male
blade also of Reliquet's instrument is that of the litho-
clast; and we need only close the blades between the
thumb and finger to be satisfied of their scissor-like action
upon the bladder.
The instrument about to be described keeps its blades
clear, and secures certain other desirable ends relating to
the injection of water, the lock, handle, etc.
Lock. The general acceptance of the cylindrical han-
dle of Thompson's instrument testifies to its convenience
as a hold for the left hand. But it is always a little
awkward to disengage the thumb of this hand, or in fact
of either hand, in order to close the lock of a lithotrite
at the critical moment of grasping the stone. This objec-
tion I have obviated, in closing the lock by rotation ot
the right wrist without displacement of the fingers. (Figs.
4 and 5.)
Wheel. In a protracted sitting, the wheel is an incon-
venient handle; its chief merit being that it affords so
insecure a grasp, that the operator is supposed to be un-
able, with its prescribed radius, to break the blades.
But in a larger instrument these blades are stronger, and
a ball may be substituted for the wheel.
Lithotrite by Collin & Cie., from a working model, a. Ball which turns the screw, b. Re-
volving cylinder-handle attached to the screw-guard, Which also revolves. This guard consists
of two square or T-shaped rods. They slide through notches in the cap of the lock. By their
revolution the cylinder-handle turns the cap and operates upon the lock. e. Cap of the lock,
which by its revolution wedges up the screws, d. Injecting pipe communicating with the
blades.
1878.] Bigelow, Lithotrity by a Single Operation.
127
Injecting tube. If the sitting be protracted, as proposed, the water
dribbles away; and the collapsing bladder, especially if trabeculated, is
liable to serious damage from the lithotrite. To meet this difficulty, my
lithotrite contains a tube or groove between the blades, for the injection
of water without removal. (Fig. 3 d.) I formerly injected water by
means of a short flat tube inserted into the urethra from time to time, by
the side of the lithotrite.
Figs. 4 and 5.
Position of the hands in holding and locking the Lithotrite. Pig. 4. Lithotrite unlocked.
Fig. 5. Lithotrite locked by a quarter rotation of the right wrist.
Blades. The blades of this lithotrite consist of a shoe, or female blade,
the sides of which are so low that a fragment readily falls upon it; while
the male blade, or stamp, offers a series of alternate triangular notches by
whose inclined planes the detritus escapes laterally after being crushed
against the floor and rim of the shoe. At the heel of the shoe, where
128
B 1 G e l o v? , Litliotrity by a Single Operation.
[Jan.
e. Male blade, presenting, on alternate
sides, triangular notches. The small
portion of debris not discharged laterally
by these notches is driven through the
slot in the female blade. /. Slot in the
female blade.
most of the stone is usually comminuted, and where the impact is there-
fore greatest, the floor is high and discharges itself laterally, while its
customary slot (Fig. G f) is made to
work effectively. It may be unneces-
sary to say that the female blade of the
common lithotrite, when drawn from a
flat plate, as in the French instrument,
has a disadvantageous cavity at the heel,
where the greatest impaction occurs by
gravitation.
One of the dangers of litliotrity, which
has been already emphasized, is the lia-
bility of the bladder to be nipped in the
instrument. In view of the character of
many of the instruments sold, we might
expect to hear more of this accident,
although indeed it is a quiet one. It can-
not be too carefully provided against, not
only by skill in the operator, but also in
the construction of the instrument ; espe-
cially during a protracted operation, while
water is escaping and the bladder collapsing. With this object, the shoe is
here wider and longer than is usual, to repel the vesical walls. (Fig. G f.)
It can hardly be doubted, that, in practice, dexterous operators secure
most stones and fragments as they gravitate into the female blade while it
depresses the floor of the bladder, perhaps a little to one side or the other,
where the stone is felt. A similar and efficient manoeuvre, especially for
a small fragment, is that of opening the blades of the lithotrite widely in
the vertical position, then slowly turning them to one side and closing
them along the floor of the bladder. If, in attempting this, the instru-
ment be opened after it is turned, the male blade displaces the fragment
without securing it ; and it is of course understood, that, in opening the
lithotrite, the blade in contact with the bladder, commonly the female
blade, is stationary. The inverted lithotrite works efficiently in a depres-
sion, if the bladder be kept out of harm's way by a special device; but
with the common lithotrite it is important to turn the blades up before
crushing, and move them, in order to be sure they are free. In the ex-
ceptional case of a stone behind the prostate, it may be necessary to invert
the lithotrite and seek it. Fragments, however, are readily washed from
this region within reach of the evacuating tube, by occasionally turning
the orifice and directing the stream from the tube upon them.
While many years ago I had not unfrequently prolonged litliotrity to ten
or fifteen minutes, and longer, it is onlv within two years that I have aimed
at the evacuation of a considerable stone durin;
12.de sitting ; and al-
1878.] Bigeloav, Lithotrity by a Single Operation.
129
though long experience will perhaps be necessary to determine precisely
what cases are unfavourable to such an operation, there can now be no
question that it is practicable to remove at once a far greater quantity of
debris than has hitherto been considered possible. The conditions least
favourable to lithotrity are obviously least favourable to this modification
of it — a stone neither very large nor hard, and especially a large urethra,
promising its best results. But if the preceding views are correct, the
future of lithotrity lies in the direction of a fast-working lithotrite, which,
while it effectually protects the bladder, is more powerful than the usual
instrument, and better proportioned to the work it is to do — a rapid com-
minution of the stone — its immediate and complete evacuation by means of
a large tube with an efficient orifice, while the fragments are gathered to
a spot where they can be aspirated, and the ready recognition and removal
of any obstruction which delays the process of aspiration. It will be no
longer essential to pulverize the stone, but only to comminute it ; and if,
in so doing, the lithotrite can be kept free from impaction, the process will
be more rapid and efficient.
During the last year I removed by lithotomy two soft stones, weighing
1272 and 1230 grains, from two male adults aged 40 and 24 years re-
spectively, who recovered after various risks. I now cannot but think,
that, with a tolerably sound bladder, a urethra o" good size, a large litho-
trite, and a large tube, the operation could have been performed with
less risk by lithotrity.
We get a useful view of the interior of the bladder by examining it in
position, through an opening in its summit. This part of the organ, and
the free and thin posterior wall, are mainly concerned in distension. The
floor of the bladder is comparatively firm and flat, and, if the subject be in
good condition, adheres to a thick mass of cellular tissue in and near the
ischio-rectal fossa1, upon which it rests. This mass is traversed by the
rectum variously distended ; and this canal, in a thin subject, may be ad-
vantageously filled with air during an operation, to facilitate its indentation
by an instrument ; reversing, for the operation of lithotrity, one of the pre-
cepts of lithotomy.
The sigmoid flexure is largely concerned in compressing the bladder
behind. The posterior wall of this viscus may be so crowded by the in-
testines that it becomes flat or even concave. A horizontal section of the
bladder is then transversely oval, flattened between the intestines behind
and the pubes in front, each of these indenting it. A well-filled or tense
abdomen tends so to shorten the antero-posterior diameter of the bladder,
that, while a large stone may gravitate backward into that part of the
bladder which is compressed by the intestines, carrying the thin wall with
it, it is not so with a small fragment, which, unless the floor be artificially
depressed, may lie on one side or the other of the vesical orifice more
readily than at a considerable distance behind it. So in sounding with a
No. CXLIX Jan. 1878. 9
130
Bigelow, Lithotrity by a Single Operation.
[Jan.
curved sound, it may sometimes be a little difficult to move the instrument
back and forth in the urethra, when its extremity may be readily turned
down upon the floor of the bladder on either side. It is seen also (see
Figs. 7 to 11), as a result of this conformation, that a lithotrite or straight
Figs. 7 to 1] . Plaster casts of bladders variously distended, and holding instruments, to show
the effect of a slight pressure in indenting the floor of the bladder, in order to facilitate the ap-
proach of fragments. The dotted line near the summit of each represents the level of an air
cavity, which makes it possible to place the cast in the exact position it occupied in the horizontal
subject.
Fig. 7. Fig. 7 a.
Figs. 7 and 7a. Side and front view of a distended bladder of singular symmetry. The original
suggests the torso of a Silenus ; the pectoral pouches overhanging the pubes ; the abdomen be-
neath the symphysis ; while the hollow loins were cushioned on the sigmoid flexure which in-
dented them. The extremity of a curved tube is seen below, at the apex of an inverted tunnel ;
and just above it, a trace of the vesical valve.
Fig. 8. Fig. 8a.
Figs. 8 and 8a. A less distended bladder, containing a straight tube which indents the posterior
wall.
1878.] Bigelow, Lithotrity by a Single Operation.
Fig. 9. Fig. da.
131
Figs. 10 and 10a. A bladder containing a large lithe-trite, which has so depressed and extended
the floor that the posterior wall rises perpendicularly.
Figs. 11 and 11a. A bladder with a very small injection, imprisoning a lithotrite.
132
Bigelow, Lithotrity by a Single Operation.
[Jan.
tube, standing at an angle of 45° with the recumbent body, abruptly
buries its extremity in the floor of the bladder near the foot of the pos-
terior wall, which then becomes more upright, and does not lie upon the
centre of an extended concave surface, as it is sometimes represented.
The deep pit at the extremity of the straight tube, and the similar depres-
sion made further forward by the curved and inverted tube (see Fig. 9),
show how readily fragments can be made to gravitate to the tube orifice,
provided the latter be not plugged by the mucous membrane. The curved
tube, when inverted, rests on the adherent floor; but the straight tube,
bearing upon the free and thin posterior wall (Fig. 8), should not be
urged too forcibly against it. In either case? the nearer the instrument
approaches a vertical position, the deeper will be the indentation. A pit
of this sort, formed in the elastic floor by an almost insensible pressure of
the instrument, explains the observation of Thompson, that, when a frag-
ment is caught by the lithotrite, many more are likely to be caught, like
fish, in the same spot. A central indentation of the floor also explains
how, in certain cases of large stone, a lithotrite may be passed back and
forth beneath it without touching it, unless the beak is tilted up. The
stone may then seem to adhere to the upper wall of the bladder, and to be
suspended from it.
Case I — Dec. 14, 1875. Age, G4. Date of symptoms, six years.
Two or three stones, measuring from half an inch to more than three-
quarters. Three sittings. First sitting: No fragments were removed
through a tube. Second sitting : Interval, seven days ; duration, forty-
five minutes, under ether ; quantity removed, " a large mass of frag-
ments size of tube, twenty -seven. Third sitting : Interval, twelve
days ; quantity removed, " a few fragments." Result : The patient was
discharged well, one week after.
Case II — May 15, 1876. Age, 60. Date of symptoms, twenty
years. Two stones, of one and one-half inches and three-quarters of an
inch diameter, respectively. One sitting : duration, one hour and a
half, under ether ; lithotrite introduced three times ; quantity removed,
one hundred and sixty-seven grains ; size of tube, twenty-nine ; there
was afterwards a slight cystitis ; no fragments Avere passed ; in two weeks
the patient was again sounded, and no fragments were found. Result :
Discharged well.
Case III Aug. 6, 1876. Age, 62. Date of symptoms, eighteen
months. Several stones, none larger than three-quarters of an inch. The
patient was confined to the house, in great pain, drawing his water every
half hour or less. The prostate was unusually large. One sitting :
duration, about one hour aud three-quarters, under ether ; size of tube,
twenty-nine. He afterwards passed a few grains of sand only. Result :
No unfavourable symptoms ; almost entire relief from pain. Later, no
difficulty in retaining water, but continues to pass catheter ; gained flesh
and former health, and resumed avocation.
Case IV Dec. 14, 1876. Age, 66. Date of symptoms, two years.
Single stone. One sitting : duration, about an hour, under ether ;
quantity removed, one hundred and eleven grains ; size of tube, twenty-
eight. Result : The patient did well for two days ; then there was a
1878.] Bigelow, Lithotrity by a Single Operation.
133
chill, with higher temperature ; pain in the back, and pain referred to
the left hip ; a gradually failing pulse ; moderate meteor ism, with but
little tenderness; death on the sixth day. An autopsy was not per-
mitted.
Case V Jan. 8, 1877. Age, 55. Date of symptoms, one year.
Single stone. A severe chill followed the primary examination. Seven
days after, the meatus was incised and enlarged from 28 to 31 Charriere.
Diameters of stone, ten to twenty millimetres. One sitting : duration,
one hour, under ether ; size of tube, thirty-one. Result : No sand nor
fragments were afterwards passed ; nor were there any subsequent symp-
toms.
Case YI April 21, 1877. Age, 43. Single stone. Necrosis. Five
years ago the pelvis of this patient was crushed. Sinuses, discharging dead
bone, opened on both hips. Six months after the injury, symptoms of
stone existed. One sitting: duration, one hour and a half, under ether;
meatus incised; size of tube, thirty; quantity removed, sixty-six grains,
and also three small pieces of bone, doubtless nuclei, one of which was
incrusted. An indurated spot was detected by the tube, where the blad-
der seemed to adhere to the pelvis. F our days after, under ether, the
lithotrite brought away with difficulty, through the urethra, a square scale
of bone, too elastic to be broken, measuring five-eighths of an inch by
seven-sixteenths, but neither sand nor fragments. Result : There were
no unpleasant symptoms at any time; and, after another careful examina-
tion for bone, the patient was discharged well.
Case YII (Dr. T. B. Curtis's case) March 6, 1877. Age, 54.
Date of symptoms, two years. Single stone. One sitting : diameter of
stone, one inch and a quarter ; duration, one hour and twenty-five min-
utes, under ether ; lithotrite introduced three times ; size of tube, thirty-
one ; quantity removed, when dry, two hundred and fifty-seven grains ;
the six largest fragments weighed together twenty-four grains ; the
strained urine yielded during the next week two and one-half grains.
Result : Rapid recoverv, with no subsequent symptoms.
Case VIII (Dr. C. B. Porter's case) Aug. 19, 1877. Age, 61. A
large, flabby man, with a feeble pulse. Date of symptoms, twenty-six
years. Two stones, one of which is so large that it is barely possible to
lock the lithotrite. Passes water every fifteen or twenty minutes. Three
sittings. First sitting : Duration, one hour and a half, under ether :
size of tube, twenty-eight ; quantity removed, two hundred and twenty-
eight grains ; passed afterwards one hundred and eight grains. Second
sitting : Interval, four days ; duration, three hours, under ether ; size of
tube, thirty ; quantity removed, seven hundred and forty-four grains ;
passed afterwards sixteen grains. No after symptoms of importance.
Third sitting : Interval, five days ; duration, three and three-quarters
hours, under ether ; size of tube, thirty-one ; quantity removed, seven
hundred and six grains ; no pain nor discomfort afterwards ; total number
of grains after drying, one thousand eight hundred and two. Result :
Discharged well, two weeks from the date of the first operation. After a
few weeks the patient could retain his water from three to four hours.
Remarks — The details of the earlier of these operations are expressed
with less exactness than I might now desire, but were dictated by myself
at the time, and are within the fact, as to the duration of each operation,
and the size of the stones. These cases, all of soft stones (i. not oxa-
134 Henry, Case of Dislocation of the Hip. [Jan.
late of lime), are the only ones by which the method which is the subject
of this paper has been tested. As statistics, they are not so numerous as
to have importance. The fatal case, without an autopsy, a circumstance
I greatly regretted, must pass for what it is worth. The other cases
abundantly illustrate what this operation is able to accomplish in remov-
ing at once a large quantity of stone by the urethra, and demonstrate a
tolerance by the bladder of protracted manipulation which has not hitherto
been recognized.
Article XT.
Case of Dislocation of the Hip upwards axd forwards ox the
Pubes, of Twenty-six Days' Standing, successfully reduced :
FOLLOWED BY COMPLETE RECOVERY. By M. H. HeXRY, M.A., M.D.,
Surgeon-in-Chief of the State Emigrant Hospitals, Ward's Island, New York,
etc. etc.
Case Joseph P., Alsatian, aged 19, height six feet two and a half
inches, well developed and muscular, admitted in the surgical division of
the State Emigrant Hospital on the evening of the 17th of October, 1873.
He furnishes the following history of his injury: On the 3d inst. he fell
from a tree — a distance of eighteen or twenty feet — to the ground, striking,
as he believes, first on his feet, then tumbling across a log, receiving a
severe blow on or near the trochanter of the left side. He was taken home
on a stretcher, but did not remain in bed beyond the second day. Being
unable to perform any labour, he entered the hospital. He could, at this
time, walk without much difficulty. From the description of his injury,
which he gave on entering the hospital, it was thought by the house-
surgeon to be little more than a severe contusion, and a careful examina-
tion was not made until several days after his entrance, when a dislocation
of the head of the femur on the pubes was discovered.
The limb was shortened, but not to any great extent — scarcely an inch;
slightly flexed, abducted, and everted. The head of the femur could be
plainly seen, as well as felt, resting on the margin of the horizontal ramus
of the pubes, on the outer side of the femoral vessels. There was some
depression along the outer aspect of the thigh, and additional prominence
over and in the region of the gluteal muscles. There was decided immo-
bility of the limb — flexion being exceedingly limited and difficult.
Oct. 23d. The patient was placed under the influence of ether, and
assisted by my friend, Dr. Thomas T. Sabine, and the resident staff of the
hospital, I attempted reduction. The limb was very rigid, and the efforts at
flexion, adduction, abduction, or circumduction, for a time met with very
limited success. By continuing the movements, together with extension,
the false adhesions, which were very complete and strong, were finally
broken up. The mobility of the joint was somewhat increased, but, as the
patient had then been under the influence of ether for some time, the
rigidity of the surrounding parts being still very great, and from fear of
exciting severe inflammation by further efforts at this time, it was deemed
1878.]
Henry, Case of Dislocation of the Hip.
135
advisable to allow the patient to recover from the effects of the steps thus
far taken.
The patient was placed in bed, and ice-bags applied over the surface of
the dislocated parts, and the limb well extended. He remained in the
recumbent posture at perfect ease \mtil Oct. 29, when I decided to make
another attempt to reduce the dislocation. The injury was one of so much
interest that I called the attention of my friends, Drs. Thomas M. Markoe,
H. B. Sands, George A. Peters, Thomas T. Sabine, and A. B. Crosby, to
the case, and they all very kindly came to my assistance. The patient
was etherized and a number of expedients resorted to without any benefit,
until the limb was strongly abducted and made to describe an arc of a
circle on a level with the patient's body, a counter-force being exerted
downward and outward by a strong broad band applied around the thigh
close to the pelvis. The head of the bone was now moved firmly, steadily,
and slowly downwards toward and into the thyroid foramen. The disloca-
tion was then reduced by strong adduction, combined with extension, and
the limb resumed its normal position, twenty-six days after the injury.
The patient was removed to his bed, and the limbs secured together by
bandages. He was kept perfectly quiet. Cold applications were applied
to the upper part of the thigh. On fully recovering from the effects of the
ether he was very much depressed, and stimulants were given, and con-
tinued, to some extent, until his complete recovery.
30th. Patient passed a good night. The thigh is very much SAvollen
and discoloured. There is but little pain. From this time the patient
made a steady and gradual recovery. He was placed on a liberal diet, and
at the end of two weeks from the time the dislocation was reduced, the
limb assumed in all its aspects, while in a recumbent posture, a normal
appearance.
Nov. 25th. Passive motion was commenced. The movements of the
joint were restricted by what seemed to be an organized infiltration among
the muscles. The restriction soon yielded to the daily efforts of motion,
which were pursued for several weeks. In the early part of January,
1874, he could walk with perfect ease and comfort, and the only feature
left to remind him of his injury was a slight awkwardness in assuming a
sitting posture, which was due to the difficulty of controlling the required
extent of flexion of the joints.
Jan. 24th, 1874. Patient was discharged cured, and went to South
Carolina to do laborious work.
I regard this case as one of interest for many reasons, mainly, however,
on account of the rarity of this form of dislocation and the time that
elapsed from the period of the injury until the dislocation was reduced.
There is also additional interest attached to the case from the difficulties
experienced in the reduction, and the subsequent complete recovery. I
should have published these particulars at an earlier day, had I not in-
tended incorporating them in a more extended article on dislocations in the
region of the pelvis. As my engagements have prevented me from pur-
suing my original intentions, I have deemed it advisable not to delay any
longer its publication. It is, as far as I am aware, the only case of suc-
cessful reduction of this form of dislocation after so long a period — twenty-
136
Chapman, Epithelioma Laryngis.
[Jan.
six days. Follin1 states that there is no case on record of this form of
luxation in which reduction has been effected beyond the eighth day. This
was Bloxam's case, referred to by Holthouse,2 published originally in the
Gazette Medicale, 1833, p. 660. Much of the interest attached to my
case lies in the complete recovery of the adjacent parts, for they were,
without any doubt, very seriously impinged upon and subjected to gome
necessary violence in the efforts at reduction.
157 West Thirty-fourth Street, New York.
Article XII.
Epithelioma Laryxgis ; Final Removal by Laryngo-thyrotomy.
By S. H. Chapman, A.M.. M.D., of Xcav Haven, Conn.
In April, 1876, a lady, Mrs. A., was sent to me for diagnosis of an
obscure affection of the air-passages. Twelve months previous to this, her
first appearance, Mrs. A. began to suffer from cough and hoarseness, and
tried change of climate for relief, but without benefit.
These symptoms increased steadily, and at the end of six months were
supplemented by slight dyspnoea, which was followed, shortly after, by
pain in the neck, at first slight and intermittent, but latterly continuous,
severe, darting. This pain affected the right side of the neck more than
the left. With the accession of pain came also another symptom, namely,
a sense of fulness and stiffness about the neck, as if the muscles were
swollen. During the month previous to her first visit, the cough had
increased in severity and become paroxysmal in type, and the dyspnoea
had so far increased as to render the patient uncomfortable and unable to
exercise freely.
Once during this month, after a severe paroxysm of cough, a small hard
nodule was dislodged from the throat, after which both cough and dyspnoea
were considerably less. During the entire year of illness, beyond metror-
rhagia of slight extent, the general health remained good.
Previous to this time the patient was in good health, had borne children,
all of whom are living and healthy, the youngest being seven years old.
Her age at time of first visit was 35 years ; figure short, thickset, face
florid, complexion clear and healthy. The chest was well-developed, and
the lungs healthy ; the neck was very short and thick ; the respiratory
act produced a slight oscillatory motion in the larynx. Pressure upon the
larynx and sides of the neck produced no pain whatever. My questions
were answered in a hoarse loud whisper, interrupted by a hard, short, dry
cough.
Upon examination, the pharyngeal space seemed to be much contracted
in size by a uniform infiltration of the pharyngeal walls, was sensitive and
also painful to the touch. For this reason, although the tonsils were not
1 Pathologie Externe, vol. iii. p. 360.
2 Injuries of the Lower Extremity, Holmes's System of Surgery, 2d edition, vol. ii.
p. 912.
1878.]
Chapman, Epithelioma Laryngis.
137
enlarged, it was necessary to use a small-sized mirror in the laryngo-
scopical examination. This examination was made with much difficulty,
on account of not only the small size and extreme irritability of the pharynx,
but also the prone position of the epiglottis, and the paroxysms of cough
induced by contact of the mirror with the walls of the pharynx.
The epiglottis and larynx were thickened, and in the condition of chronic
inflammation observed of the pharynx. Both vocal cords were deeply
congested and slightly thickened, and were the seat of three abnormal
growths. Near the posterior insertion of the left vocal cord, attached to
its inferior surface near the edge, was situated a small nodule the size of a
millet-seed. The edge and a portion of the upper surface of the middle
third of the right vocal cord were occupied by a cauliflower growth, spring-
ing from a broad base, sufficiently pendulous to move up and down during
respiration, and about the size of a pea. To the border of the anterior
fourth of the right vocal cord was attached another and similar but smaller
growth. These growths were grayish-white in color, felt hard to the
touch, and bled readily. Nothing abnormal was recognized as regards the
shape of the larynx or the co-ordinate action of its muscles.
In Fig. 1, this primary condition is represented. This and the other
figures are above life size, and the rima glottidis is partly open.
Fig. 1.
The treatment was begun in the usual manner by an attempt to over-
come the pharyngeal and laryngeal irritability by daily use of the mirror
and bougie ; but at the end of a month this condition had not improved;
in fact it was decidedly worse, notwithstanding that treatment by means
of inhaler and astringent spray had been carefully used. In addition to
this, the cervical pain increased in severity and the tumour rapidly enlarged.
Hence it was determined to proceed at once to operation. An attempt
was made to produce local anaesthesia by pencilling the larynx in the
following manner.
Six applications were made at a single sitting, with a solution of acetate
of morphia, six grains to the drachm, followed by twelve of chloroform,
with no local and but slight general anaesthesia as a result. Sixteen
hours thereafter, twelve applications of the morphia solution, and twenty-
four of chloroform were made during a period of two hours, wTith no local
anaesthesia produced, until the general anaesthesia became too profound for
operation.
This plan was therefore abandoned and the more successful one adopted
of fatiguing the laryngeal and pharyngeal muscles by repeated use of a
good sized bougie, until a point was reached wiiere all spasmodic action
ceased. This process required a period of about three hours, during which
138
Chap m a n , Epithelioma Laryngis.
[Jan.
the bougie was introduced several hundred times. Within a week after
this plan was adopted the tumours were extirpated to their bases and the
latter severely cauterized.
My excuse for giving so minute a description of the operation is that
the case is unique in the difficulty experienced in overcoming the irrita-
bility and in the method adopted.
Fig. 2 represents the condition after completion of the operation. The
operation increased the cervical pain and produced slight oedema glottidis,
which yielded readily to inhalations of vapour of benzoin. The conscious
and permanent results of the operation were relief from cough, dyspnoea, and
pain, and change of voice from a hoarse whisper to a rough, loud baritone.
Fig. 2.
Microscopical examination of the growths disclosed the characteristic
nests of the epitheliomatous variety of cancer. This diagnosis was verified
by two other competent observers.
On my return to the city in September, the patient presented herself
again, after an interval of six weeks, presenting all the symptoms pre-
viously described and in severer form. The tumour of the left vocal cord
had not returned, but those of the right had not only returned but had
increased beyond their former size.
Laryngeal and pharyngeal infiltration had also increased, and with it
more acute irritability. From this time until the middle of November,
repeated attempts by the methods before described were made to com-
pletely extirpate the newly -formed tumours ; but, although many times the
original mass was removed, the rapidity of growth was so much greater
than that of removal, and the sympathetic inflammation of surrounding
tissues became so extensive, that operation by the mouth was reluctantly
abandoned.
On November 25, 1876, on account of alarming dyspnoea, laryngotomy
was performed. The operation was entirely finished in the space of two
minutes, because of the use of the admirable Fuller's tracheotomy tube,
consisting of a bivalve enclosing a closed tube.
The bivalve was first removed from the enclosed tube, the tissues over-
lying the crico-thyroid space were divided with a bistoury, the crico-
thyroid membrane was divided with a single stroke ; the bivalve, pressed
so that the points came together forming a wedge, was passed through
the slit thus made, and the inner tube forced into place through the bivalve.
Thus the crico-thyroid membrane was pressed apart, and prevented, by
close apposition with the tube, any hemorrhage from entering the trachea.
The patient remained in an atmosphere impregnated with vapor of benzoin
for two days, and on the third day was about her house as usual.
1878.]
Chapman, Epithelioma Laiyngis.
139
Fig. 3 represents the condition immediately preceding the operation.
Two weeks later the operation of laryngo-thyrotomy was performed for
removal of the abnormal growths. Ether was given, and with good effect,
through the tracheotomy tube; as^soon as the patient was well anaesthe-
tized, the tube was withdrawn, the opening enlarged upwards to the level
and to the right side of the tubercle of the epiglottis, the ahe of the thyroid
cartilage Avere separated by lateral pressure, so much as was necessary for
fully displaying the abnormal growths, and these, together with the right
Fig. 3.
\
ii
vocal cord were then removed with strong forceps. Hemorrhage gave
some trouble during the operation, and obliged a suspension of it occasion-
ally, in order that by turning the patient over with head downwards, the
large tubes might become emptied of blood. After completion of the ope-
ration a Fuller's tube of the size Hso. 30, French scale, was introduced,
and the patient put to bed in an atmosphere of benzoin vapor. The only
untoward circumstance attending the operation was the premature occur-
rence, during operation, of menstruation, which to some degree weakened
the patient. For some days following the operation the tube became
rapidly occluded with muco-purulent discharge, the respiration was slightly
accelerated, mucous rales could be heard over the entire chest, the tempe-
rature was raised one degree and a half, and the pain and stiffness of the
neck were greatly aggravated. By the middle of January, however, these
symptoms having entirely disappeared, the seat of the extirpated tissue
was thoroughly cauterized with chloride of zinc, the cauterization being
repeated four times at intervals of two days, the patient using meanwhile
an inhaler with tinct. benzoin and ether. Laryngoscopies! examination
at this time showed that the growth and right vocal cord had been
thoroughly extirpated, that the false vocal cord of the right side was much
tumefied, and that the left side of the larynx, beyond some congestion,
appeared to be healthy. The general health at this time was entirely
restored, the patient following her usual avocations, and expressing herself
as much gratified at her freedom from all suffering.
For some weeks after the operation the patient was able to speak in a
loud and rather clear voice, owing to the tumefaction of the right false
vocal cord which compensated for the loss of the true cord ; but this capa-
bility was gradually lost as the tumefaction diminished, and the voice
returned to a dull, monotonous, loud whisper. During April, when the
patient again presented herself, no return of the disease was recognizable
by laryngoscopical examination, but the tube was allowed to remain for
fear of its recurrence.
140
Bus ey, Bromide of Potassium in Pregnancy.
[Jan.
Fig. 4 represents the condition at this time. In June a small growth
appeared on the anterior third of the right laryngeal surface, whicii was
removed by forceps, and the base touched with zinc chloride. This growth
did not show by microscopical examination the appearance of epithelioma,
but that of mucous polypus. Again, in July, the growth of June started
up afresh and was severely cauterized.
Fig. 4.
On September 26, the date of the last examination, no appearance of
disease could be detected beyond slight thickening of the tubercle of the
epiglottis.
There seems to be some probability, however, of the recurrence of the
disease, and hence the tracheotomy tube is allowed to remain in situ.
Article XIII.
Bromide of Potassium in the Uncontrollable Vomiting of Preg-
nancy. By Samuel C. Busey, M.D., Washington, D. C, President of the
Medical Society of the District of Columbia.
As it is my purpose simply to set forth the utility of the potassium bro-
mide in the treatment of this obstinate, but, fortunately, rare complication
of pregnancy, 1 will not undertake any comparison of the relative merits
of the numerous agents which have been recommended by their respective
advocates. In the accomplishment of this object I am fortunate enough
to possess the memoranda of two cases prepared by competent and impar-
tial observers, to which cases I was called through their kindness and par-
tiality. The first case occurred in the practice of my friend, Dr. P. J.
Murphy.
Case I. " Mrs. McC, white, aged 28, a very stout and robust married
lady, never had been pregnant, though married for five years, suffered a
great deal at her menstrual periods from pain in the back and lower part
of abdomen, flow always scanty, lasting usually but one day, very nervous
and excitable. After treatment of several months the above symptoms
were relieved, and she became pregnant in the spring of 1874. Two weeks
subsequent to the date at which the menses should have occurred, profuse
1878.]
Busey, Bromide of Potassium in Pregnancy.
141
salivation ensued, several dozen handkerchiefs being required during the
twenty-four hours ; there was obstinate constipation, relieved temporarily
by enemata, constant vomiting, the simplest nutriment being ejected. The
various remedies recommended in such cases were tried, oxalate of cerium,
minute doses of calomel, effervescing nitrate of cerium, iced champagne,
etc., but to no purpose. My patient becoming alarmingly prostrated, I
called to my assistance Dr. Busey, who ordered drachm doses of potass,
bromide in tAvo tablespoonfuls of beef-tea, injected per rectum, every four
hours. This treatment completely arrested the vomiting in a few days,
and with it all the nervous phenomena passed away. Mrs. McC. was now
in the fifth month of pregnancy, and enjoyed comparatively good health
until towards the close of the sixth month of pregnancy, when she aborted,
the abortion arising partly from her debilitated condition and partly from
undue excitement on hearing of sudden bad news."
To the above notes Dr. Murphy is kind enough to append the following
history of the second pregnancy of the same lady : —
" In the summer of 1876 she again became pregnant, and the same
phenomena which accompanied her first gestation were again observable.
She was then under the care of an eminent physician in New Jersey, and
her condition became such that I was telegraphed for, her friends suppos-
ing her to be in a dying condition.
" The physician in attendance had exhausted all his resources, and had
called in another to assist him. When I arrived her condition was very
critical, pulse small and thready, 120 per minute, great restlessness, skin
hot, tongue dry, brown, and furred, great pain over epigastrium, and all
the symptoms accompanying great exhaustion.
"I recommended the treatment pursued with such success in her former
sickness, and left, asking to be informed of the result.
" Almost immediately after the third injection she was relieved. Mrs.
McC. went to full term, and I had the pleasure of delivering her of a fine
healthy female child."
The second case exhibits more markedly the salutary effects of the
potassium bromide. It occurred in the practice of Dr. Mackall, whose
extensive experience and accurate observation entitle his opinion to the
highest consideration. The following extract from a letter from him fur-
nishes the preliminary details of the case : —
Case II. " Mrs. E.'s husband consulted me in my office about the 25th
of April, 1877, with reference to her condition. He stated that his wife
was three or three and a half months pregnant with her first child, and
had been free from nausea and vomiting until a few days prior to his see-
ing me ; but that these symptoms had suddenly become marked and dis-
tressing. As she declared that she would not see a physician, he thought
it best that I should prescribe without visiting her. Accordingly I directed
some simple medicine (I think, trisnit. of bismuth). On the following
day I learned that the medicine had afforded no relief. It was, therefore,
discontinued, and oxalate of cerium substituted. This also failed, and,
from the description of her condition, I felt that her Avish not to see a
physician should be no longer regarded. On visiting her I found her very
ill ; pulse barely perceptible, extreme restlessness, extremities cold, vomit-
ing incessantly. During the night and morning she had repeatedly ejected
blood, and was still now and then vomiting it up in quantities of a table-
142
B u s e y , Bromide of Potassium in Pregnancy.
[Jan.
spoonful or more. The tip and sides of the tongue were red and glazed.
Great tenderness on pressure over the epigastrium. She had not slept,
nor retained a particle of food for two days.
" During the next twenty -four hours there was no recurrence of the
haematemesis, but otherwise her condition remained unchanged, although
every means that suggested itself was faithfully tried.
" Another day passed without improvement. No medicine, no form of nu-
triment could be retained by the stomach (her only support was by means of
nutritive and stimulating enemata). A blister applied over the pit of her
stomach, morphia injected hypodermically, starch, and laudanum enemata
and other measures failed in accomplishing material benefit. A vaginal
examination being made, marked anteflexion of the womb with enlarge-
ment and tenderness of the fundus was revealed. I now requested her
friends, who had been previously apprised of her danger, to have you called
in consultation, and you are familiar with its subsequent history. I will
leave to you the further description of the case, together with the treatment
adopted. In conclusion, however, I desire to express my conviction that
the large enemata of bromide of potash, which you suggested, were mainly
instrumental in relieving the gastric irritability. I would also state that
when the nausea and vomiting were arrested, they ceased, I may say.
abruptly, and did not again recur, except for a few hours once or twice
several weeks after her convalescence.
" Further, to show to what extent the patient had been reduced, I men-
tion the fact that she could not be even raised up in bed for about four
weeks, and six weeks or more elapsed before she could be lilted into a chair
for a few moments.
" I saw Mrs. E. this morning; she is now perfectly well, and for several
months has been free from any unpleasant symptoms."
In addition to the symptoms enumerated by Dr. Mackall, there were
present at the time of my first visit great tremulousness followed by sink-
ing, which came on in paroxysms, usually occurring when any person un-
expectedly approached her bedside, or when any effort to move was made.
The pulse was barely, if at all, perceptible,, the surface was cold, capillary
circulation very languid, voice very feeble, and, when any attempt was
made to speak, retching immediately ensued. Her expression was anxious
and distressed. Forty grains of the potassium bromide dissolved in a
mixture of one ounce of beef-tea and a half ounce of brandy, to which
were added ten drops of laudanum, were ordered to be administered per
anum every four hours. The stomach to remain at rest, nothing whatever
to be given per orem until further orders. The beneficial effects were
manifest after the third enema, and, when 480 grains of the bromide had
been administered, the nausea and vomiting had entirely ceased. After
the first twenty -four hours the interval between the enemata was length-
ened, and she was allowed to take nutriment in very small quantities at
short intervals by the mouth. Even after the discontinuance of the nausea
and vomiting, and suspension of the bromide and nutritive enemata. the
alarming prostration was so persistent, notwithstanding the ingestion of
what seemed to be an adequate amount of nutriment and stimulants by
the mouth, that the propriety of induction of abortion was entertained and
discussed. During this period, which continued several days, the brain
seemed overwhelmed by the exhaustion, even though the heart had regained
in a measure force and rhythm. Happily, however, interference was de-
layed, the expectant plan of treatment persisted in, and complete reaction
1878.] Smith, Paralysis of Abductors of Vocal Cords,
143
ensued. As stated by Dr. M. she is now well, and expects to be confined
during the ensuing month of November, 1877.
As a rule, the bromide, in doses varying from 30 grains to one drachm,
dissolved in beef-tea, to which brandy and laudanum may or may not be
added, should be given every four hours until the nausea and vomiting have
ceased, and the stomach will retain some bland food, and stimulants if
necessary, and then it should be gradually withdrawn by extending the
intervals between the enemata. This treatment has not failed in any case
which has come under my observation ; but the practitioner must not
imagine that with the suspension of the nausea and vomiting the case is
concluded. The effects of the deprivation of food and fluids, together
with the nervous and circulatory disturbances, may seriously protract con-
valescence, and excite the gravest apprehensions.
In conclusion, I must add that the method of treatment is not original
with me. To Dr. Girabetti is due the credit of having first suggested
O CO
and successfully applied this mode of administering the potassium bromide
in obstinate vomiting of pregnancy. He administered it in increasing
doses, giving 92 grains the first day, 8 grammes the second, and 10 the
third ; after which he lessened the dose in proportion to the effect produced.
October 1, 1STT.
Article XI Y.
Case of Paralysis of Abductors of Vocal Cords ; Tracheotomy ;
Recovery ; Relapse ; Death. By Andrew H. Smith, M.D., Surgeon
to the Throat Department of the Manhattan Eye and Ear Hospital, New York.
F. C, aged 50, native of Ireland, messenger, came to me Sept. 8, 1877,
suffering from urgent dyspnoea, which he stated had been coming on for
two years, but had grown rapidly worse during the previous fortnight,
until the night before he had suffered so much that he thought he should
not live until morning.
A laryngoscopic examination showed at once the cause of the difficulty
to be complete paralysis of the posterior crico-arytenoid muscles. The
ligamentous portions of the vocal cords were in perfect apposition, leaving
only a triangular opening about a line and a half in extent each way
between the vocal processes of the arytenoid cartilages. This small
opening was all the space available for breathing, and even this was
lessened whenever a powerful inspiratory effort was made. Expiration
was unimpeded. The vocal cords were reddened and somewhat thickened.
The voice was husky, but retained its laryngeal character.
The patient gave a clear history of specific lesions contracted fifteen
years ago, and followed at intervals since by consecutive symptoms. Foil-
years ago had facial paralysis, which lasted eight months. Had had cough
and profuse expectoration for some months, and had been troubled for
years with an anal fistula, which discharged very freely.
There was apparently some degree of dulness at the apices of both lungs.
1 4 i Smith, Paralysis of Abductors of Vocal Cords. [Jan.
Auscultation gave no very satisfactory results, owing to the impeded
respiration; but it was evident that chronic bronchitis existed, with more
or less of bronchial spasm.
Feeling that the patient's life was every moment in jeopardy, I sug-
gested tracheotomy, to which he readily assented, and the operation was
performed at the Manhattan Eye and Ear Hospital on the following day.
The trachea was more than usually irritable, and the coughing caused by
the insertion of the tube was very violent and long continued. Indeed
this irritability constituted a very awkward feature of the case throughout,
and was, perhaps, the indirect cause of the unfavourable result. The
slightest interference with the tube would provoke a furious paroxysm of
cough, which would continue until the patient was almost exhausted.
Changing the canula for one a little smaller was not attended by any good
result, and morphia had to be employed to obtain any rest.
Considering that the paralysis probably depended upon a gummy deposit
somewhere in the track of the inferior laryngeal nerve, I put the patient
upon liberal doses of iodide of potassium, with half a grain of the prot-
iodide of mercury, three times a day. In the course of about two weeks
the paralyzed muscles were found to have regained their action to a slight
degree, and then direct faradization by means of the laryngeal electrode
was resorted to. The improvement was very rapid, and in two weeks
more the movements of the glottis seemed to be almost normal. Meantime
the cough was excessively wearing, and great quantities of mucus were
expectorated through the tube. The patient complained of a great deal
of tightness and wheezing in the chest, which was but little relieved by
treatment. As his strength was breaking down, and the larynx was now
acting very satisfactorily, the cause of the paralysis being apparently under
control, I determined to risk the removal of the tube. For a few days
the cough was less severe, but it soon became as bad as ever, so that I
was doubtful whether the presence of the tube had had as much to do with
it as I had supposed. The expectoration of mucus was not lessened, and
the auscultatory signs were those of chronic bronchitis with asthma. The
patient gained ground, though slowly, for the next three weeks, and then
began to lose again, complaining of increasing tightness of the chest. On
the evening of the 28th of October I was summoned to see him, and found
him in the condition of a person with a moderately severe attack of asthma.
It was easy to see that the dyspnoea had its origin in the lungs and not in
the larynx, and an examination with the mirror showed that the glottis
was acting as well as at any time previously. A dose of morphia hypo-
dermically gave marked relief. The following evening I called again,
and found the patient in the same condition. I did not then make a
laiyngoscopic examination, but repeated the injection, with the same
result as on the evening before. Twenty -four hours later I was summoned
in great haste. The patient's wife told me that he had had great difficulty
of breathing all day. The moment I saw him I perceived that his condi-
tion was widely different from what it was at my previous visit. The
difficulty was now plainly laryngeal, and the first glance with the mirror
showed that the cords were again in close apposition.
The wound had so nearly healed that no air entered by it into the
trachea, though a little escaped during expiration. With some difficulty
a No. 8 catheter was introduced, but, though the breathing was relieved,
the cough which resulted was so violent that the patient would not permit
the instrument to remain. I therefore left him, to procure the necessary
1878.]
Porchee, Case of Molluscum Fibrosum.
145
instruments and assistance to introduce a canula, but when I returned he
was dead. I was told that I had scarcely left the room when he rose from
the chair in which he had been sitting and went to the bed and lay down.
A moment after, without any noise or struggle, he ceased to breathe. It
is probable that overfilling and consequent paralysis of the right heart was
the immediate cause of death, rather than direct asphyxia, for when I left
the patient be was able to walk about, and though breathing with great
difficulty his face was but slightly dusky, and actual suffocation appeared
not to be immediately at hand.
Doubtless the recurrence of the laryngeal paralysis was due to the
exhaustion caused by the asthmatic attack.
110 East Thirty-Eighth St., New York, Nov. 17, 1877.
Article XV.
Case or Molluscum Fibrosum ; Tubercles of an Unusual Size. By F.
Peyre Porcher, M.D., Professor of Clinical Medicine and of Materia Medica
and Therapeutics in Medical College of State of South Carolina, Charleston.
This patient entered the City Hospital in November, 1876, and
remained there for some months. He asked for his discharge, and no fur-
ther accounts have been received from him. In the following description
are included some notes kindly furnished by Dr. F. P. Lewis, of Colleton
County, S. C, then an under-graduate, who had known the subject whilst
at his home in the country, and was instrumental in bringing him to the
city.
Solomon Youngblood, colored, aged 17, native of Colleton Co., S. C,
was first seen March last (1876), at which time he had from seventy to
eighty tumours on his person. These varied in size from a large-sized
water bucket to that of a pea, resembling tubercles, sacks and soft, flabby,
pendulous " cutaneous purses." The largest tumour he says is congenital.
This remained stationary, of the size of a pigeon's egg, until he was six years
old, and was located between the shoulders ; since that time it has grown
very much and gravitated downwards, until now it hangs in folds from
the left buttock, reaching as far down as the knee. Another, growing
just below and to the inner side of the knee, and as large as a cocoanut,
rests on one of the same size just below it — these two being attached by
constricted necks. Between these one was taken out about eight years
ago, weighing eleven pounds. During the operation there was a good
deal of hemorrhage. This tumour when cut into presented a grayish
appearance and consisted seemingly of dense fibrous tissue. Another
tumour grows from his left groin, and still another just below his left
breast ; each of these is about as large as an egg. One on his wrist is
about the size of a walnut ; the remainder are smaller.
Since the time mentioned above these tumours have increased in size
and number, the one on his groin, having grown rapidly, has gravitated
downwards, and has coalesced with that below the knee. His mother
No. CXLIX Jan. 1878. 10
146 Muhlenberg, Case of Membranous Entero-Colitis. [Jan.
has a tumour of a similar kind, between the shoulders, and about the size
o"1 an egg. His general health is moderately good, circumstances bad,
living in much exposure, badly clothed, with scanty food and of bad
quality.
Nothing of interest occurred in the history of the case whilst in hospital,
no efforts made by me to improve his condition being of any avail. His
appetite and general health were good, and he made no complaints, except
of the chafing caused by his clothes, which had to be cut unsymmetrically
to cover the redundant growth hanging from one side of his body. The
tumours visibly increased in size, during his three months' stay in the
hospital.
He was carefully weighed in January, the weight of another person of
apparently similar height and size was obtained, and the difference, fifty
to fifty-six pounds, was taken as the probable weight of the growth.-.
Messrs! G. R. Sparkman and John Forrest were present at the weighing
and superintended it. His weight before entering the hospital had been
145 pounds.
This case resembles in some particulars Octerloney's, only mine is per-
haps even more remarkable, especially as regards the size of the tumours
and the immense extra weight which the boy was forced to carry.
By a microscopical examination, very incomplete however, which I
made, the tissue appeared to be of a dense fibrous structure. I am inclined
to consider these growths to consist simply in an unusual hypertrophy of
the dermoid tissue, not very dissimilar to elephantiasis, and I think it
likely that their development takes place in the corium specially; for we
find that Kolliker (in his Manual of Human Histology, vol. i. 110, Syden.
Soc. Loud.) points out that the corium " is principally composed of con-
nective and elastic tissue, containing in addition smooth muscles, fat-cells,
bloodvessels, nerves, and lymphatics, in great abundance.'" So we have
elements enough here and specially fitted to aid in producing inordinate
development, as occurs analogously, also,, where there is enormous growth
of the scrotal tissue when required to accommodate large hernial protru-
sions.
I notice since writing the above, that Niemeyer states that M. sim-
plex (Fibroma molluscum of Yirchow) results from " a circumscribed hyper-
trophy of the connective tissue of the skin." Practice, vii. 397.
Article XVI.
A Case of Membranous Extero-Colitis. By W. F. Muhlenberg, M.D.,
of Reading, Pennsylvania.
The patient, a married lady aged about fifty-five years, was first visited
by me on the 1st of February, 1877. She had lost three brothers by
tubercular affections between the twentieth and thirtieth years of their
lives, and one son by diabetes ; and her father and mother had both been
1878.] MthlexbeeCt, Case of Membranous Entero-Colitis. 147
subject to the gout, of which her father died, although her mother was still
living, aged over eighty years. She herself had been subject to dysentery
and diarrhoea, and, while residing in Europe, had suffered from an in-
testinal inflammation for six months, which the doctors there pronounced
" schleim-fieber," or a mucous fever.
When called in, I found her suffering from an acute attack of unilateral
pleuritis, together with complete derangement of the gastric function.
Six months previously I had attended her for a small infra-scapular car-
buncle. During the previous four months her bowels had been alternately
constipated and relaxed ; and during that time she had complained of a
general feeling of malaise, together with intestinal disturbance, all forcing
her to keep her bed most of the time, but she had neglected consulting a
physician. During the treatment for pleuritis, 1 administered effervescing
citrate of magnesia in tablespoonful doses as an agreeable febrifuge ; but
noticed that it had a marked deleterious influence on the condition of the
bowels, and soon discovered, in the stools that were passed, immense quan-
tities of the "membranes" or "skins," pathognomonic of membranous
enteritis.
These membranes varied in length from one inch to a yard, and in
breadth from a line to three or four inches. None of them were tubular.
Sometimes they seemed to be only "■mucous shreds;" but at other times
complete casts of the intestinal mucous membrane, including representa-
tions of the glands, follicles, and folds ; examined microscopically and
chemically, they presented the usual characteristics of these discharges,
showing themselves to be entirely mucous. There was, in addition,
steady pain radiating from the umbilicus, a tender spot on pressure
below the left scapula, a general feeling of soreness over the entire
abdomen — localized, however, more particularly in the regions of the ileo-
cecal valve, sigmoid flexure, and transverse and descending colon. No
spinal tenderness was present. The slightest movements of the body in-
creased these pains, which had been noticed before the pleuritis, but were
somewhat masked by it. The pain at the ileo-caecal valve and sigmoid
flexure was of that burning character peculiar to gastric ulcer, and was
very much aggravated by any manipulations. The bowels, as in the pre-
vious three months before I saw the case, were alternately constipated and
loose ; but unfortunately before this time the evacuations had not been
ocularly inspected. The discharge of these " skins" took place almost
daily, although occasionally every second day, and varied in quantity
from a pint to a chamber-vessel-ful. Only t'wice during the progress of
the disease was any blood noticed in the stools, and then it was probably
due to internal hemorrhoids. The stools at no time were scybalous, but
were generally frothy.
After the subsidence of the pleuritis, the condition of the patient was as
follows : The pulse, normally 50, registered 70 beats to the minute, was
very soft, compressible, slightly irregular, and thin ; the skin was cold,
dry, and frequently resembled the so-called cutis anserina ; the temperature
of the body was 97° Fahr., and showed a slight increase in the morning;
the memory was very much blunted, and sleep much disturbed by dreams.
There was alternate constipation and looseness of the bowels. The feet
and hands were continually cold, and there was slight stagnation of the
circulation in the extremities. The tongue, at first flabby, soon cleaned,
but resembled the "strawberry tongue" of scarlatina, and was full of
cracks, wliich were always more numerous and deeper before the dis-
148
Muhlenberg, Case of Membranous Entero-Colitis.
[Jan.
charge of the "skins." The body was much emaciated, but more par-
ticularly in the abdominal region, where there was extreme hollowness, so
that the spinal column could be easily reached by manipulation. Tympa-
nites and gurgling, however, were almost constant symptoms. The patient
was excessively nervous and depressed ; while slight neuralgic pains occa-
sionally showed themselves along the spinal column, where, however, no
tenderness could be detected. Every morning a hectic flush could be
noticed on the cheeks ; and a nervous, dry cough was present for quite a
time. " Cold creeps" were frequently noticed along the spinal column.
The menopause had taken place, and there was no uterine trouble. No
heart affection could be detected, and there Avas only a slight increase of
hepatic dulness. There was no kidney trouble, as the urine, although
slightly diminished in quantity, but pale, was nearly normal. A chill, fall
in temperature, an increase in the cracks on the tongue, and abdominal
symptoms invariably preceded the discharge of the " membranes."
Iron and opium increased the abdominal pains and quantity of the dis-
charge. Quinia in the smallest quantity produced excessive headache
and ringing of the ears. Alcohol, except in the shape of a very light
native Clinton wine, and milk, totally disagreed.
The patient was directed to use every morning a rectal injection of luke-
warm water, to be followed in half an hour by the injection of a fluid-
ounce of the following mixture in six ounces of water: R. Tincturse
benzoini comp., f gss ; tincturse opii, f3iss ; extract! hsematoxyli, 5ij ; olei
cubebre, f 3iij ; misturae acacise, q. s ; aquce ad f^iv. Ft. mistura. S.
Two tablespoonfuls as directed. The back and legs were rubbed morning
and evening with a stimulating liniment, and the surface of the abdomen
was very lightly brushed over with the same. Every morning and even-
ing one of the following powders was taken: R. Pulveris ergotse, gr.
xxv ; plumbi acetatis, gr. iss ; bismuthi subnitratis, gr. xlv. Ft. pulvis
in sex chartulas dividenda. S. One as directed. For a short time the
syrup of the lactophosphates of iron, quinia, and strychnia was used, but
had soon to be discontinued, owing to the idiosyncrasy of the patient. A
tight flannel binder over the abdomen and perfect recumbency in bed were
insisted upon.
The diet, restricted to beef-tea and dry toast, was steadily persevered
in ; and all the drinking water used was first boiled. No other food than
this just mentioned was used for five months, and even at present the beef-
tea forms the staple article of the diet. The ergot and sugar of lead were
used until prudence dictated their discontinuance, when the following pills
were substituted: R. Argenti nitratis, gr. ij ; cupri sulphatis, gr. iv ;
terebinthinse canadensis, 3SS- Div. in pil. xxiv. S. One after each
meal. These pills were artificially hardened before being used, so as to
pass, if possible, the stomach unchanged.
Under this treatment there was a very gradual improvement, until, on
the 1st of May, the patient was allowed to leave her room. The frequency
and quantity of the discharges had materially lessened. They took place
only about once a week, instead of once a day, and, instead of being
" skins," were nothing but " shreds" in very diminished quantity. The
patient slowly gained strength, and the abdominal soreness and pain mate-
rially abated. Under the use of the injections, the pain and soreness in
the descending colon and sigmoid flexure of the rectum entirely disap-
peared, until at last the only tender spot on the abdomen was at the ileo-
cecal valve. The memory improved, and sleep became more steady. The
1878.] Muhlenberg, Case of Membranous Entero-Colitis. 149
chills and " cold creeps" almost entirely disappeared, and the circulation
in the extremities became more active. Fowler's solution of arsenic, in
three-drop doses three times a day, was then commenced, and agreed and
acted very favourably. The muriated tincture of iron was tried for a short
time, but soon disagreed. Contrary to the generally expressed opinion,
exercise in this case proved very injurious, and was always followed by a
discharge of the " skins."
On the 1st of June, the patient left the city for a short visit, and returned
much improved.
During June, and since that time, a peculiar squamous eruption has
shown itself on the skin ; before that time, an extravasation, very much
like purpura hemorrhagica, was noticed on the arms and legs. The spots
after a short time became yellow in colour, and the places where they had
appeared looked as if they had been bruised. Since that time her condi-
tion has improved, until at present she passes no " skins" at all, and has
not done so for the last twelve weeks, and before that not for four weeks.
Her natural colour has returned, her appetite is good, and she has gained
in flesh more than she had lost. At present she takes moderate exercise,
walks about, visits her immediate neighbours, and says she feels stronger
than ever before.
The assignable causes of this disease may be the following, but to which
we must ascribe it, it is difficult to say : 1. An inflammation of the mucous
membrane of the intestine, produced by piles. 2. Repeated attacks of
diarrhoea or dysentery. 3. Possibly a, so to say, skin affection of the in-
testines. 4. Drinking of a hard limestone water. 5. Residence in a
damp house — surrounded very densely by trees. 6. A tuberculous affec-
tion of the intestines.
The diagnosis of this affection is easy as soon as the membranes are seen
in the stools ; but before that, or if they have not been examined, it is
rendered probable by the following symptoms : Alternate constipation and
looseness of the bowels. Pain and soreness in the intestines ; unattended
by much fever. Tender spots in other parts of the body. Suspicious lung
symptoms. Excessive nervousness, with marked loss of memory. Chilly
sensations, more particularly affecting the spinal column. The peculiar
cracked appearance of the tongue. The harsh, scaly skin, and low animal
heat. The slight relief of pain and intestinal soreness after the discharge
of the stools. The feeble circulation in the extremities, and the premising
of the case by some cutaneous disorder, more particularly by boils and
carbuncles.
The boiling of the ivater, the exclusive diet, and perfect rest, together
with the use of stimulating liniments, seem to have effected more in the
amelioration of this case than anything else, although the action of the
ergot and of Fowler's solution has apparently been beneficial.
An admirable account of this disease and its treatment, by Dr. Da Costa,
will be found in the number of this Journal for October, 1871, p. 321.
150
Morton, Two Cases of Nerve Stretching.
[Jan.
Article XVII.
Two Cases of Nerve Stretching. By Thomas G. Morton, M.D., Sur-
geon to the Pennsylvania Hospital. Reported by William C. Cox, M.D.,
Assistant Surgeon to Philadelphia Orthopaedic Hospital, and Surgeon to Out-
Department of the Pennsylvania Hospital.
Case I. Neuralgia of Arm and Shoulder from a Wound of the Ulnar
Nerve; Nerve Stretched; Cured On the evening of February 11, 1877,
Miss B. dropped a pair of scissors and in catching after them the handles
struck on the arm of her chair and the upturned points entered the outer
side of the right wrist with so much force, that she was obliged to pull them
out with the other hand. The wound bled very little, but the pain was
intense from the fingers to the shoulder. The patient had been sick for
three months, and was just convalescing from typhoid fever at the time the
accident occurred ; a laudanum dressing was immediately applied. The
wound healed within two weeks, but the pain in the hand and wrist con-
tinued to increase, and gradually it involved the elbow, shoulder, and side.
The patient was never free from pain ; at times a dull ache, and again
very severe, especially after the least use of the hand. Dr. Morton was
first consulted March 22d. It was found that the pain was increased by
pressure at the place of injury ; small blisters were then applied, and the
following week belladonna and glycerine ; there being no improvement, a
week later, strong aconite liniment was substituted ; this application was
continued for three weeks. Sewing and writing were found to be espe-
cially painful; there was also sensation of numbness and cold in the hand.
Dr. Morton thought it advisable to try the effect of stretching the ulnar
nerve, for the pain was evidently increasing, and all treatment had proved
abortive ; on May 3d Dr. Mitchell saw the case in consultation, and fully
agreed as to the proposed operation. On May 7th the pntient was etherized,
and an incision three inches long was made directly over and on a line
with the nerve at the wrist ; the nerve was carefully examined at the place
of puncture, but no sign of any enlargement or hardness or change in any
way could be detected. The nerve was then isolated, and the forefinger
carried under it, and the cord was well stretched ; after the nerve was re-
placed, it apparently was considerably lengthened, from its wavy appearance
as it lay in position. The wound was brought together with silver sutures,
and the hand placed on a splint. The pain in the arm after the effects of
the ether had passed off was intense, notwithstanding large doses of morphia
used hypodermically. A few days later an abscess formed in the upper part
of the wound, which discharged through the opening near the wrist. For
several weeks a feeling- of numbness and tino-ling continued in the little
and ring fingers and upon the outside of the hand, but gradually these
symptoms disappeared ; at no time was there a total loss of sensation in
the ulnar distribution. The wound healed nicely, but left a hard cicatrix,
tough and ropy. In a month the pain had ceased ; sewing and writing
still produced an ache, which was participated in by the whole arm and
shoulder. This gradually diminished ; but, as the patient was of a rheu-
matic temperament, it may have been aggravated by that condition.
Dec. 1. The patient's arm is quite well, without the least symptom of
.impaired nerve action; sensibility and muscular power perfect ; the only
1878.] Morton, Two Cases of Nerve Stretching.
151
noticeable change being a wearied sensation in the arm and shoulder after
much use of the hand or fingers.
Case II. Neuralgia of the left Leg and Foot; Stretching, of the Sciatic
Nerve — H. K., carpenter, aged 52. In August, 1866, he fell twenty-five
feet from a scaffold upon a stone* pavement, striking his buttocks ; the
left leg was found flexed, with the foot under the right knee, and turned
on its outside, with the iron part of a hatchet under the head of the fibula.
He was taken up insensible, and remained in that condition more or less
for ten days, and had some difficulty of speech for four weeks. Was
examined by Drs. Arnold and Longshore of Hazelton, who were unable
to find any fracture or luxation ; the urine was bloody for five days follow-
ing injury, and catheterizing was found necessary twice daily for ten days.
At the end of six weeks he became perfectly rational, but showed paralysis
of both legs. This continued for three months, when the right leg showed
an improvement, and at the end of five months the patient was able to
leave his bed and move about on crutches ; still he had no power or sensa-
tion in the left leg. At the end of another month sensation had gradually
returned. He improved slowly until April, 1867, when he was seen by
Dr. Casselberry, of Hazelton, who found him suffering with acute articular
rheumatism, all the large joints being implicated. Had never had syphilis.
Soon after recovery he complained of excessive pain in sole of left foot,
without heat, no swelling, no constitutional disturbance, no increase of
pain on pressure ; there was loss of sensation of foot, and half way to the
knee, entire on the outside of leg, and partial on inside. The pain in the
sole of the foot increased until it was excruciating. Temporary relief was
only obtained by the use of large doses of morphia. Pain continuing, Dr.
Casselberry excised a portion of the plantar nerves ; relief followed for
seven years. In 1874, suffered from pain in the great toe, which extended
over the anterior part of the foot. The pain gradually increased, and
involved the leg as well as the foot. From the pain and morphia, the
patient's health wras thoroughly broken down. June 12, 1877, the patient
arrived in the city with his physician, Dr. Casselberry, and consulted Dr.
Morton, who recommended, at first, stretching of the sciatic nerve rather
than any nerve excision, and in this was supported by Drs. Mitchell and
Hunt, who saw the case in consultation. The patient was suffering so
intensely from pain that the operation wTas performed at the patient's urgent
request at the Orthopaedic Hospital the same day ; after etherization the
sciatic wTas readily reached in the middle of the thigh, and was thoroughly
stretched ; the fore finger was passed under the nerve, and then by draw-
ing upon the nerve the limb was twice lifted free of the bed. The nerve
trunk after the stretching had also the appearance of marked elongation,
more than filling its normal place in the wound. The incision healed at
once, no suppuration. The patient insisted on going to his home in
Wilkesbarre on the second day after the operation. For five days he had
spasms, or twitchings, of the muscles of the leg and thigh, with exquisite
sensitiveness along the course of the sciatic and popliteal nerve, but this
gradually subsided, and on the 1 2th day this symptom disappeared. Pain
in the old location, however, still continued, and injections of morphia were
used daily. Some weeks after this, the suffering being very great, Drs.
Casselberry and Longshore excised two inches of the external popliteal,
which is said to have given entire relief.
In the case of the ulnar nerve stretching, the increasing pain, which had
not only involved the hand and arm, but had extended to the patient's
152 Hunter, Radical Cure of Inguinal Hernia. [Jan.
neck and side, has been entirely relieved by this operation, which certainly
inflicts far less injury than any nerve excision. In the case of the sciatic
nerve stretching, the operation did not give any relief ; it was unfortunate
that the patient left the hospital so soon after the operation, for this in
itself may in a measure have militated against any good the operation
might reasonably have been expected to afford.
Article XVIII.
Use of the Testicle in the Radical Cure or Inguinal Hernia. By
Charles T. Hunteii, M.D., Demonstrator of Surgery in the University of
Pennsylvania.
Among the very many expedients to which surgeons have resorted in
their efforts to establish a radical cure in cases of inguinal hernia, the
human testicle, so far as I have been able to learn, has never been utilized.
The following unique case of a patient who was sent to me for advice, by a
brother practitioner, is so remarkable, and the result so satisfactory to the
patient himself, that I have considered the case well worthy of record : —
Mr. P., oet. 22, medical student, a strong and unusually well-developed
man, free from all traces of either hereditary or acquired disease. Six
years ago, as a consequence of some violent exertion, Mr. P. sustained a
rupture in his right groin. After the subsidence of the immediate effects
of the injury, Mr. P., with the advice of his physician, tried various trusses
and other means to keep the hernia within the abdomen. His efforts to
obtain relief by the use of trusses were of no avail, for in spite of every
truss applied, some portion of the hernial contents would slip past the pad
of the instrument, and thus render his condition worse than it was with-
out a truss. After three years of ineffectual efforts to find an instrument
that would afford the desired relief, Mr. P. almost unconsciously got in
the habit of keeping the hernia reduced by gently pressing with his hand,
concealed in his pocket, the testicle of the affected side up against the
margin of the external ring. In order to facilitate this manipulation Mr.
P. had a long pocket put in his pantaloons on the side on which the rup-
ture was situated. With his hand in this pocket, supporting the testicle
against the edge of the inguinal ring, Mr. P., while fitting, standing, or
walking, kept the hernia up and the ring closed. After pursuing this
peculiar treatment for about a year, greatly to Mr. P.'s surprise, he found
that the testicle had become firmly fixed in the external abdominal ring,
and afforded a complete barrier against a descent of the hernia.
Mr. P., eight weeks before calling on me for professional advice, con-
tracted gonorrhoea ; three weeks subsequent to the attack of gonorrhoea,
epididymitis of the retracted testicle occurred, from which Mr. P. expe-
rienced intense suffering. The pain attending this attack of inflammation
of the epididymis was doubtless greatly intensified by the resistance of the
surrounding tissue to the swelling of the inflamed gland.
On a careful examination of Mr. P.'s case, when I first saw him, I
1878.] Haynes, Case of Purulent Pelvic Effusion.
153
found the right testicle quite firmly fixed within the columns of the external
abdominal ring, effectually closing the outlet of the inguinal canal through
which the hernial contents formerly escaped into the scrotum. The barrier
afforded by the presence of the testicle at the ring, without the aid of a
truss or other retentive means, has* been adequate thus far to keep the
rupture in place.
When I first examined Mr. P. neither coughing nor violent straining
of any character was sufficient to displace the gland from its present ab-
normal position behind the columns ; this fact I have verified by two sub-
sequent careful examinations. The right half of the scrotum, which
formerly contained the testicle, has contracted to nearly one-half its nor-
mal size in consequence of disuse.
The most interesting feature of this extraordinary case is the remote
possibility of displacement of the right testicle from its present location,
and a subsequent reappearance of the rupture in consequence of the vis
a tergo to which the testicle will be constantly exposed.
During the entire period of the patient's unconscious treatment of him-
self, there were no symptoms of inflammation in the right groin about the
testicle ; hence it is probable that the testicle is not held in its present useful
position by inflammatory adhesions. If, then, the testicle of this patient
have no direct vital connection with the margin of the external ring or
the sides of the inguinal canal, its retention in its present position, appa-
rently at least, is dependent on diminution of the size of the external
abdominal ring by approximation of its sides or columns towards each
other, and shortening of the right spermatic cord.
In order that Mr. P. may retain what has already been accomplished
in such a remarkable way in his case, I have advised him to carefully
avoid all violent muscular exertion for several months, and to keep a
compress secured by a spica bandage upon the right groin.
Article XIX.
A Case of Purulent Pelvic Effusion, opening spontaneously into
the Vagina. By W. H. Haynes, M.D., Late Resident-Physician to the
Presbyterian Hospital ; Attending Physician to the Eastern Dispensary, New
York.
In the number of this Journal for April, 1877, Dr. Brick ell writes :
" That he has never seen spontaneous discharge through the vagina of a
pelvic effusion; nor, from the anatomical position and relations of this
canal, would he anticipate such a thing." To add to the evidence ad-
duced by Dr. Atlee, in the July number of this Journal, where he gives
cases in which the opposite of Dr. BrickelPs conclusion occurred, I refer
to a similar case, reported in the American Supplement to the Obstetrical
Haynes, Case of Purulent Pelvic Effusion.
[Jan.
Journal of Great Britain and Ireland, for April, 1877, page 4, and quote
the following from the records of my own very limited experience : —
P. C, a female, aged twenty-eight, born in Germany, married, house-
keeper, admitted to the Presbyterian Hospital Feb. 17, 1877. Family
history good. A resident of this country twenty-one years. Married eight
years ; but has never been pregnant. Up to present illness, has always
menstruated regularly. Six years ago, had what was called inflammation
of the womb ; since which time she has been in poor health and under
continual treatment for uterine trouble.
Three months ago, while menstruating, symptoms of pelvic cellulitis
developed ; followed by a severe attack of that disease. About the fourth
week of its duration, after a hard passage from her bowels, she felt a sudden
gush, which she found to be a discharge of matter from her vagina. This
has kept up ever since, attended with pelvic pain and loss of flesh.
At the time of her admission she was very anaemic and emaciated. Had
a copious greenish, offensive discharge from vagina. Pain across small of
back and in hypogastrium, preventing perfect rest. Coated tongue ; poor
appetite ; fever ; and a small, rapid pulse.
On examination per vaginam, there exists, about a finger's length within
the ostium, on the right side of the posterior wall, an orifice readily admit-
ting an English catheter and leading to a large abscess in the recto-vaginal
septum. The uterus is enlarged, displaced, and bound down away over
to the left side. All the tissues feel hard and thickened. Rectum and
bladder sound.
The sinus was slit up a short distance, giving free vent to a quantity of
pus, and a plug put in. Warm disinfecting vaginal injections, with qui-
nia, iron, and cod-liver oil internally, was the plan of treatment pursued,
with material benefit to the patient. Later on injections of carbolic acid
and tincture of iodine were made into the cavity of the abscess. Notwith-
standing all means of treatment she has recurring attacks of pelvic inflam-
mation, followed by a profuse discharge of pus, confirming the statement
of Thomas (Dis. of Women, 4th ed. p. 457) that u one or more abscesses
may discharge themselves by long sinuses which fail to allow of their
complete evacuation, and may continue to pour out pus for months, or even
1878.]
155
REVIEWS.
Art. XX Transactions of the International Medical Congress oj
Philadelphia. 1876. Edited for the Congress by John Ashhurst,
Jr., A.M., M.D. Royal 8vo. pp. xlix., 1153. Philadelphia, 1877.
This large and closely printed volume is offered by the editor as "a not
unsatisfactory memorial of the meetings of that important body of which
it records the acts — the first International Medical Congress of America,"
and if the words "very satisfactory" be substituted for the modest "not
unsatisfactory," the characterization is accurate. No small part of this is
due to the knowledge, care, and good taste of the editor, than whom no
one could have been found more competent or pains-taking, and while
none but those who have tried somewhat similar work can properly ap-
preciate the amount of labour which has been bestowed on this volume, it
is clear enough that all members of the Congress, and especially those who
contributed either papers or comments, are under obligations to him for
the result.
All readers of this Journal are probably familiar with the circumstances
which led to the assembly in Philadelphia last year of the largest body ot
medical men which has ever met on this continent; and those who wish
for details as to the preliminary work of organization will find them in a
brief sketch of the work of the Centennial Medical Commission, by Dr.
J. H. Hutchinson, which follows the editor's preface.
The title of "International Medical Congress" does not by any means
express the true character of this assemblage, although it would not be
easy to find a better one which would be sufficiently brief.
Strictly speaking, there are but two papers in the volume which relate
to medical matters of "International interest," viz.: those on Quarantine
and on a Universal Pharmacopoeia; and the first three hundred pages are
occupied with the Centennial Addresses, which are decidedly the reverse
of international in character.
These addresses, eleven in number, taken together, give a very good
view of the history of medicine in this country, and will be valuable to
future writers for the biography, and more especially for the bibliography
which they contain ; but one cannot help wishing that either some of the
lecturers had adhered more closely to their texts, or else that the editor
should have been allowed, and been willing, to consolidate their produc-
tions somewhat.
One of them, that on Mental Hygiene, by Dr. Gray, is neither historical
nor bibliographical, and is thus in strong contrast to the rest ; it is devoted
to advocating the claims of religion, and to objecting to the scientific
theory of culture as set forth by Huxley, Tyndall, and other scientists,
but nothing definite is offered in its place, except some suggestions from
Bulwer's novel "The Caxtons," which are certainly good in themselves
so far as they go.
The majority of the addresses are, of course, highly laudatory in char-
156
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[Jan.
acter, as suited the occasion, but there are two marked exceptions. Dr.
Bowditch, in the address on Hygiene, presents a summary of the answers
obtained by him, from all the States and Territories except one, to a series
of twenty questions upon the actually existing condition of Preventive
Medicine in the several States, and the results which he got were, as he
says, very unpalatable.
It appears that in a large majority of the States no attention is given to
the matter, no willingness is manifested to spend money for the support of
Boards of Health, for scientific investigations of the causes of disease, for
the repression of noxious and offensive trades, or for the prevention of the
adulteration of food ; and, in short, that the work of organization for pub-
lic hygiene has yet, for the most part, to be done. Its necessity and
vitality are, however, beginning to be perceived by the people, and there
is good hope for the future.
The second exception is in the address on Medical Jurisprudence. Dr.
Chaille, having collected his data, probably sat down to prepare the history
of progress and improvements in medical jurisprudence due to America,
with somewhat of the feeling of the historian of Iceland when he compiled
his celebrated chapter on the snakes of that country. His record of what
has been left undone, and of what ought to be done, is decidedly larger
and more important than that of what has been done, and his suggestions
for improvement are interesting and valuable. Since he wrote, his idea
of substituting for coroners a corps of medico-legal officials has been car-
ried out in Massachusetts, and although his demand that these officials
should be " specially trained as medical experts* and attested as compe-
tent by competent judges" has not, and in fact could not at present be
complied with, still a step in advance has been taken, and a great one,
which if persisted in will create a demand for a class of men which now
can hardly be said to exist.
Both of the addresses just referred to come under the general head of
State Medicine, a term not familiar in this country, because of the total
absence of the thing itself, and because of the want of men properly trained
to take charge of such subjects. Medical Jurisprudence and Public Hy-
giene belong together, like the blades of a pair of scissors ; the way to
make them powerful and useful is to join them, and this should be borne
in mind in any attempts to organize a body of Medical officials, avIio are
to be in the service of the State.
Upon the other addresses, by Drs. Flint, Wormley, Eve, Toner, Parvin,
Yandell, Davis, and Woodward, we shall not attempt to comment ; the
names of these authors are sufficient proof of their interest in an historical
and literary point of view, and we will pass at once to the reports and
papers presented to the Sections.
The first paper among those presented to the Section of Medicine is
that of Dr. Woodward, U.S.A., entitled, Typlio -malarial Fever: is it
a Special Type o f Fever ? After calling attention to the mortality in
armies from disease, the remarks of Virchow upon the small losses of
the German army during the late war with France, as compared with the
great mortality in the American armies during our recent war, are dis-
cussed. Virchow thinks that the good results were due to the fact that
"we possessed the inestimable experience of the Americans, and, finally,
we had German science." But it is shown that if the losses for the seven
months of the German war be compared with the losses of the first seven
months of our own war, with which only they can be fairly compared, the
1878.] Transactions of International Medical Congress, 1876.
157
discrepancy is not nearly so great as Virchow supposed. There is a dif-
ference, however. The German figures give a mortality 1.9 -f- per 1000
monthly, while our own statistics show a mortality of 2.7 per 1000 monthly.
While admitting that this is in part due to better discipline and a wiser
application of preventive medicine on*the part of the Germans, Dr. Wood-
ward thinks that much should also be attributed to the malarial influences
to which our troops were exposed, and this leads to a discussion of the
effects of malaria as complicating the ordinary camp diseases, and espe-
cially typhus and typhoid fevers. By a very interesting, complete, and
accurate historical account of the diseases of armies in malarious regions,
and especially in Hungary and the Netherlands, it is shown that hybrid
forms of fever due to malaria are the rule and not the exception, and this
is followed by a sketch of the so-called typho-malarial fever of our own
war of 1861-65. This term was proposed by Dr. Woodward, not to re-
present a specific type of fever, but "to designate all the many-faced brood
of hybrid forms resulting from the combined influences of the causes of
malarial fevers and of enteric fever."
When the name "typho-malarial fever" was placed upon the Army
Medical Monthly Eeports, no special official circular was issued defining it,
and there is no doubt that cases were reported under this head which did
not belong to it as not having enteric lesions. But the work of Dr. Wood-
ward on Camp Diseases was in the hands of almost all medical officers,
and in this the meaning of the term is made plain enough, so that the
error in taking large numbers of cases such as the medical statistics of the
war present is probably slight, although the safest viewT is that of Dr.
Woodward, that the statistics do not show the proportion of typhoid fever
and malarial fever cases which actually occurred.
His conclusion is that typho-malarial fever is not a special type of fever;
that it cannot be considered as a new disease ; that whenever an army
recruited in a comparatively non-malarial region campaigns on a malarial
soil, such hybrid forms will appear, and that sporadically such cases will
appear in civil practice in miasmatic regions. After some debate the fol-
lowing conclusion was adopted by the Section.
' ' Typho-malarial fever is not a special or distinct type of disease, but the term
may be conveniently applied to the compound forms of fever which result from
the combined influence of the causes of the malarial fevers and of typhoid fever."
In his discussion of the 'question, Are Diphtheritic and Pseudo-mem-
branous Croup Identical or Distinct Affections'? Dr. J. Lewis Smith
takes the ground that they are essentially different.
Admitting that it is impossible to make a clear and certain diagnosis of
croup where diphtheria is endemic, he bases his argument mainly upon
cases which occurred in New York prior to 1857, at which time diphtheria
became established in the city, upon observations of physicians in locali-
ties where diphtheria does not prevail, and on opinions collected from
medical literature, all of which, he considers, prove that one is non-conta-
gious and the other highly contagious ; that they occur at different ages,
jhave different sequehe, and are not alike as to results of treatment. He
gives the results of microscopic examination of the diphtheritic membrane,
and of diphtheritic lesions of the kidney and air-passages, made by Drs.
Satterthwaite and Heitzmann, of New York, in cases carefully observed by
himself; and concludes, that "neither the microscope nor chemical tests
show any qualitative differences which hold good as a means of distinguish-
ing the false membrane of croup from that of diphtheria," but that there
158
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[Jan.
is sufficient difference in the relation of the false membrane to the under-
lying tissues, in the condition of the blood, and in the lesions found in the
kidneys, to warrant the opinion that they are essentially distinct.
In the debate which followed, the conclusions of Dr. Smith were op-
posed by Dr. Pepper, and the final result, although not formulated, was
that as yet we have not sufficient data to decide the question, although the
balance of probability seems to be that there may be a specific element in
diphtheria which was wanting in the sporadic croup of thirty years ago.
In answer to the question Do the Conditions of Modern Life Favour
specially the Development of Nervous Diseases ? Dr. Bartiiolow re-
plies in the negative. Referring to ancient writers, he shows that several
varieties of insanity, as well as apoplexy and epilepsy, were known to
them. Erb's inference that neuralgia must have been rare, because
Aretams is the first who describes it clearly, he replies to by a reference
to the remarks of Socrates on the relation of pleasure and pain, but an
examination of the remarks rather strengthens Erb's point than other-
wise. He concludes that the apparent increase of insanity shown by re-
cent statistics is due to more accurate registration, that as the longevity
of man has increased it is improbable that his nervous system has become
more vulnerable, and that the reason why we hear more about nervous
diseases in modern times is that they are more accurately studied and
differentiated.
In the debate which followed, the weight of opinion seemed to be in
favour of a belief in the increase of nervous diseases in modern times, due
to stimulants, methods of education, syphilis, etc.
The contribution to the Etiology of Epilepsy, by Dr. Neftel, is a case
of injury of the head which was followed by epileptiform attacks, persistent
headache, and the development of a painful zone on the right side of the
head and face analogous to the so-called epileptogenic zone produced in
Guinea-pigs, experimentally, by Brown-Sequard. The symptoms described
are in the main subjective: as Dr. Neftel remarks, 'kwe entirely miss the
result of an objective examination as regards sensibility and motility, the
ophthalmoscopic appearances, the condition of the pupils, the presence of
sugar, albumen, or blood in the urine, etc. To this we would add the
effects of anesthetics. The results of treatment by the galvanic current
were, as Dr. Neftel states, quite surprising, in fact they remind us of the
celebrated case of Dr. Beddoes and Sir Humphry Davy, in which a case
of paralysis was cured by putting a thermometer under the tongue, and we
should like to have seen the effects of the metallotherapia of Burq applied
in this case.
The first conclusion drawn by Dr. Neftel is —
I. "It is made evident by the case described, that in a perfectly healthy per-
son, free from any hereditary disposition, epilepsy can be brought on by traumatic-
influences upon the head, causing cerebral commotion without structural lesion of
the brain."
This conclusion seems hardly warranted by the case presented, since it
is not clear that there was no structural lesion of the brain, and if this be
omitted the conclusion is a very old one, viz., that epilepsy may result from
injury of the head.
The second conclusion is more cautiously stated, and is undoubtedly
correct, i. e —
1878.] Transactions of International Medical Congress, 1876. 159
1 ' Further investigations will be needed to prove that such traumatic in-
fluences during childhood ma)' constitute a most frequent etiological factor in the
production of epilepsy."
They will also be needed to prove that epilepsy is usually due to disease
of the pineal gland, or to obstruction of the perivascular cerebral lymph
spaces.
Dr. Charles Den is ox begins his article on The Influence of High
Altitudes in the Progress of Phthisis by saying : "It is assumed that this
occasion calls for something suggestive, leading an inquiring mind to look
at an important subject in a new light, and seeing the errors of former
beliefs through a change in the channels of thought." This is a little dis-
couraging ; and when we get a little further, and find phthisis defined as
"a slow death commencing in the lungs," the case becomes very doubtful.
Finally, when we come to see the results based on an analysis of 66 cases
of phthisis, and the absolute unconsciousness of the author that there is
such a thing as calculating the probable limits of error in statistics, and
that his figures can by no possibility give even a distant approximation to
reliable results, we must give it as our opinion that the ten conclusions to
the paper can only be considered such in the sense that they are at the
end of it, and that no evidence is presented that altitude per se has
any special effect in cases of phthisis, which, be it clearly understood, is
not equivalent to saying that it has no effect.
The short paper by Prof. Lebert on the Treatment of Simple Ulcer of
the Stomach contains nothing specially new, but is a practical, common
sense resume of the indications for diet in this affection.
Passing over for a moment the paper on Pernicious Anaemia, we come
to Dr. E. M. Hunt's article on Alcohol in its Therapeutic Relations as
a Food and as a Medicine, which is given only in abstract. It is a review
of the literature of the subject, with the following conclusions : —
"I. Alcohol is not shown to have a definite food value by any of the methods
of chemical analysis or physiological investigation.
"II. Its use as a medicine is chiefly that of a cardiac stimulant, and often ad-
mits of substitution.
*'III. As a medicine it is not well fitted for self-prescription by the laity, and
the medical profession is not accountable for such administration.
"IV. The purity of alcoholic liquors is, in general, not as well assured as that
of articles used for medicine should be. The various mixtures when used as medi-
cines should have a definite and known composition, and should not be inter-
changed promiscuously.' '
These conclusions were furnished to the Woman's National Christian
Temperance Union and two other Temperance Societies, as the answer of
the Section to their request for scientific data, and we hope they were
found satisfactory. We do not think that the first two are correct, pre-
ferring the views of Drs. Brunton, Sanderson, and Gull, presented to the
select committee of the House of Lords, viz., that alcohol is a true food,
an inconvenient and unnecessary food in health, but very convenient in
some diseases.1
The first paper in the Section of Biology is on the Microscopy of the
Blood, by Dr. Christopher Johnston. This gives a very excellent
and impartial summary of our knowledge of the morphology of the blood,
and it merits careful reading by those who propose to investigate ques-
tions of pathology connected with this fluid. The paper is not one ot
1 Lancet, Oct. 13, 1877, p. 512.
160
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[Jan.
which any brief summary can be given, and we select but one point for
comment, choosing it because it bears upon another article in the volume
which we have passed over for a moment, viz., that on Pernicious Pro-
gressive Aneemia, by Dr. R. P. Howard, of Canada. The point which
we wish to emphasize is that the day for estimates and opinions about the
size of blood corpuscles, or their number, has past. The summary given
by Dr. Johnston in regard to the micrometry of blood corpuscles shows
what care and accuracy is required to obtain satisfactory results in measur-
ing blood corpuscles by means of eye-piece micrometers, and even when
this has been done with all possible care, another observer cannot verify
it. The method used by Dr. Woodward of photographing blood corpuscles
and micrometer together seems destined to supersede all others, since by
it the diameters may be measured with the greatest possible accuracy, and
one can repeat the measurements at his leisure. In like manner the in-
troduction of the hamiatimetre for the purpose of counting the number of
corpuscles in a given quantity of blood, while in scientific precision im-
measurably in advance of the old methods, still needs to be connected with
photography, and it does not appear difficult to obtain data of both measure
and number in the same negative.
Now, keeping these facts in view, turn to the paper on Pernicious
Ancemia, by Dr. R. P. Howard, of Montreal, just alluded to, and imagine
what results might have been attained had the haematimetre of Hay em
and the micro-photometric process of Woodward been applied to the study
of these cases. Even as it is, the paper is an interesting summary of what
is known with regard to a rare and singular disease, of which at least
three new cases are given as observed by Dr. Howard.1 The author
recognized the importance of microscopic examinations, and such were
made, but there is nothing definite in the record. It is said in one case,
for instance, that " the red corpuscles looked natural, a few only were
crenated ; a somewhat unusual variation in size was noticed among them.
Many measured scarcely the 5 qV o °^ an mcn m diameter, as seen with the
No. 9 (immersion)." As a record of dimensions this is useless for pur-
poses of comparison, and we have no counting of corpuscles at all ; in
other words, no definite data as to the degree of anaemia. What is given
under this head corresponds to the old-fashioned way of indicating degrees
of fever ; what is wanted is the precision which would correspond to
clinical thermometry.
When we remember the rarity and obscurity of these cases, the fact
that the great majority of physicians must be content to see them through
the eyes of others, that the observations cannot be repeated and verified
as in a chemical experiment, for the opportunity once gone is gone for-
ever— we cannot but insist strongly upon the importance of processes like
those of Dr. Woodward, in which personal equations are eliminated, and
a record is obtained which is unimpeachable.
Photo-micrography is not merely a process for procuring pretty pictures,
or a time-saving substitute for the camera lucida ; there is nothing mys-
terious about its manipulations, nor does it require costly and complicated
apparatus, and the day is not far off when every well-educated physician,
especially when dealing with questions of pathology or medico-legal in-
vestigations, will use it as regularly as his microscope.
1 Consult in this connection Habeiiein, Casuistischer Beitra°; zur progressiven, per-
niciosen Ansemia. Med. Corresp.-Blatt. des WUrtembl. arztl, Yer. Sept. 20, 1877,
p. 193.
1878.] Transactions of International Medical Congress, 1876. 161
It is not intended to depreciate in any way the value and interest of
Dr. Howard's paper — the defect pointed out is common to all papers on
this subject — and it is a defect which will require years to remedy, he-
cause of the rarity of such cases. Let us hope that the next case of per-
nicious anaemia will mark a proper beginning of the history of this
disease.
The paper by Dr. Austin Flint, Jr., on the Excretory Function of
the Liver, gives his latest conclusions on a subject which is peculiarly his
own ; but even his summary1 is too long to give here, and it cannot be
condensed. It was adopted as expressing the opinion of the Section.
Dr. Harrison Allen's contribution on the Mechanism of Joints is an
abstract of a more elaborate paper, which, if properly illustrated, will be
of interest to surgeons as well as anatomists. We do not like the terms
static and dynamic as applied to joints, nearly in the sense of fixed and
moving, and think it would be better to coin new words to express the
peculiar relations to which Dr. Allen refers.
The Surgical Section of the volume begins with a report on Antiseptic
Surgery, by Dr. J. T. Hodgen, of St. Louis, in which many authorities
are quoted, and the various methods which have been used are pointed
out. The general tone of the paper is unfavourable to the special form of
application known as "Lister's method," as the author does not believe it
possible to protect wounds from the contact of catalytic germs ; but it is a
little curious that this method is not directly alluded to or described, nor
is any reference made to the results claimed to have been obtained by it.
This deficiency is in part made up by the full report of the remarks of
Prof. Lister, in the discussion upon the paper, in which the technik of
the method is fully described. Dr. Hodgen calls attention to the fact that
putrefaction may occur in the body in sites so remote from mucous or cu-
taneous surfaces, that we cannot suppose that "germs have been introduced
either by air or water, and, in the debate, suggests that they may be in-
troduced through the blood. This suggestion seemed to Dr. CannifP to
prove that all antiseptics were useless, which is very bad logic. Such
cases, as Prof. Lister remarks, are very rare, and not all ill-smelling pus
is putrefactive ; tlVey should be looked on as special phenomena which
require more careful investigation than they have yet secured. Undoubt-
edly bacteroid forms may exist in the blood ; we have so found them in
animals apparently perfectly healthy, and it is barely possible, though very
improbable, that Dr. Hodgen's explanation may be correct.
One reason why the advocates of antiseptic surgery, including Professor
Lister himself, have not made more rapid headway in overcoming oppo-
sition to it, is that they base their arguments mainly on & priori grounds,
viz., on the methods of origin and diffusion of germs. Neither in Dr.
Hodgen's paper nor in the discussion which followed it, including Mr.
Lister's remarks, is any use made of the actual results obtained, and as a
record of facts the statistics and results given by German surgeons, and
especially by Prof. Thiersch, would outweigh the whole of it. Professor
Lister himself is an accomplished microscopist and a very skilful and pa-
tient experimenter, and it no doubt seems to him that the results which
he has obtained with his apparatus are conclusive ; but it is necessary that
one should have pursued the same line of investigation to see the force
of the argument. What the average surgeon must judge by are results ;
1 See Medical News, Oct. 1876, p. 163.
No. CXLIX Jan. 1878. 11
162
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[Jan.
he wants to know how many times the knee-joint has been opened in this
way, and with what sequelae ; how many abscesses of spinal origin have
been " Listerized," and what happened as compared with the same num-
ber of similar cases treated in the next ward by his unbelieving colleague
Mr. Spence.
No doubt if one will go to Mr. Lister's clinic, and follow his cases. ].<-
will be satisfied ; but that is a course open to few.
If the managers of the Royal Edinburgh Infirmary would publish fully
and accurately the details of all surgical cases treated therein for the last
two years, we should probably know what at present we can only conjec-
ture, doubt, or believe.
Professor Van Burex's paper on the Treatment of Aneurism is an
excellent summary of the various modes of treatment of the larger aneu-
risms, with critical remarks which fully bear out the author's reputation
as a practical surgeon. The method of Mr. Tufnell. of Dublin, for the
treatment of internal aneurism by rest, position, and diet, is approved; but
the use of drugs for slowing the action of the heart or favouring coagula-
tion is looked on with doubt.
AVe have seen a case of innominate aneurism in which apparent con-
solidation was brought about by distal pressure and the use of veratrum
viride, so given as to keep the action of the heart at about fifty beats per
minute, and although the final result was bad, it would seem that veratrum
is an adjuvant worth trying, especially since the fact, that the mortality
from ligature after compression has failed is greater than if the ligature
is used at once, induces Dr. Van Buren to teach that when it is decided
to try compression, every means should be used to obtain prompt success,
and these failing, that the effort should not be prolonged.
In speaking of gluteal aneurism, the suggestion is made (originally
made by Dr. Frank Woodbury1) that by controlling the artery within the
pelvis by the introduction of the hand into the rectum, the old operation
could be rendered safe.
It is made clear, as the author states, that " the treatment of aneurism
at the present day does not consist, as thirty years ago, in a choice be-
tween ligature and compression, but involves judicial weighing of the
claims of many remedial measures, and his own conclusions, which were
adopted as expressing the opinion of the Section, are as follows : —
"I. Tiifnell's treatment of aneurism by rest, position, and restricted diet, offers
a valuable resource in thoracic and abdominal aneurism.
"II. It should always be tried in innominate, subclavian, snbclavio-axillarv.
and iliac aneurisms, before resorting to measures attended by risk to life.
" III. For aneurisms of the subclavian and iliac arteries, the Hunterian opera-
tion, with our present means of preventing secondary hemorrhage, is not justi-
fiable.
" IY. For reasons formally set forth by Holmes and Henry Lee. the "old
operation' cannot properly be formally substituted for the Hunterian operation in
these cases, but should be held in reserve for special cases.
" Y. It is the most safe and surgical resource in gluteal aneurism, if the circu-
lation can be commanded by the hand in recto.
" VI. The mode of cure by embolism, aimed at in the method of manipulation,
is a not unfrequent explanation of what is called spontaneous cure of aneurism.
" VII. The value of Esmarch's bandage in the treatment of aneurism is prob-
ably not fully estimated.
1 Am. Journ. Med. Sci., Jan. 1874, p. 131.
1878.] Transactions of International Medical Congress, 1876.
163
" VIII. In view of the promising features presented by the cases of Levis and
Bryant, in which horse-hair was introduced into an aneurismaJ tumour, the repe-
tition of this operation, or the substitution for the horse-hair of Lister's prepared
catgut or other animal substances, may be properly tried."
The paper by Dr. Sayre on Morbus Goxarius gives an excellent ac-
count of the symptoms of the disease, and of his methods of treatment,
which are characterized by good practical sense, and which undoubtedly
give good results. It contains nothing that will be specially new to those
acquainted with his previous teachings on this subject, and we will simply
notice his second conclusion as being the only one not adopted by the
Section, viz., that this disease is almost always of traumatic origin, and
not necessarily connected with a vitiated constitution. This was objected
to by Prof. Gross, who believes that it can only occur in a person "whose
constitution is in a state of degradation, or who is labouring under some
constitutional taint." He considers that the matter from an abscess con-
nected with hip-joint disease is of the same character as that expectorated
in pulmonary consumption ; in other words, that it is essentially scrofu-
lous or strumous.
As remarked by Mr. Lister, " in affections dependent on strumous dis-
ease, there are great varieties of pus," and we hardly think that Professor
Gross could have intended to assert that there is such a thing as a pecu-
liar, pathognomonic, scrofulous pus. The point is of interest mainly as
bearing on the question of treatment, although we cannot assent to Dr.
Sayre's statement that if the disease is of constitutional origin, it cannot
be cured by local means. So far as causation is concerned, the truth
seems to be that some cases are due to injury and some to constitutional
causes ; but in each class the local method of treatment will give very
satisfactory results, and this in part, as pointed out by Dr. Sayre, because
it is the best means of putting the patient into such a condition that he
can have fresh air, good food, and other things necessary, or at least ex-
tremely useful, in removing the constitutional debility or dyscrasia.
Dr. Gouley reports A Case of Subperiosteal Excision and Disarticu-
lation of the entire Inferior Maxillary Bone for Phosphorus Necrosis*
but instead of furnishing information, he requests it. This is the germ of
a very valuable idea, and may lead to the development of a new field in
medical literature, viz., the stating as clearly as may be just what one does
not know. It is not so easy to do this as one might imagine, and even
Dr. Gouley has not entirely succeeded. In his tabular list of operations,
although he carefully refrains from telling where the reports of any of
the cases which he indicates can be found, yet this excessive caution
will make it difficult for his correspondents to help him. The case given
is reported only incidentally, to show what kind of information is wanted,
and in what shape it should be given ; but one point is not quite clear.
He says that u the pathological description of the parts removed will be
given elsewhere." Must we infer that those who are to send the reports
of their cases to the author for his information should also give the pa-
thology elsewhere ?
It is also not clear why no information is desired with regard to removal
of anything less than the entire jaw, since there is nothing peculiar that
we know of in total excisions performed one-half at a time, over excisions
of one-half or two-thirds of the bone ; but, as remarked above, the paper
was not designed to give information, so we cannot complain.
Dr. Mastix's article on The Causes and Geographical Distribution of
Calculous Diseases, gives much less of the geography than we had hoped
164
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[Jan.
to see. He states that he has tabulated over three thousand eases of
lithotomy in America, but the tables are not given, and these are the
very things which must be given to make such a discussion of permanent
interest or value, since it is only after their examination that intelligent
criticism is possible.
The remarks of Professor Dugas upon the Treatment of Penetrating
Wounds of the Abdomen, although brief, are important, and it is to be
regretted that there was no discussion of them in the Section, as we pre-
sume was the case from the absence of record. We believe the conclu-
sions of the author to be correct, although his chief premise seems erro-
neous, for the cause of the rapidly fatal issue in such cases cannot properly
be called septicaemia.
Be that as it may, it is highly important that prominent surgeons should
give the weight of their authority to the only mode of treatment which
offers any hope of success ; for, as the matter now stands, the average
practitioner is afraid to interfere, in view of the medico-legal complica-
tions in which he will probably be involved. Dr. Dugas does not support
his opinions by quotations, and writes as if he considered that he is alone
in holding them ; but this is not the case, as will be seen by consulting
the second surgical volume of the Medical and Surgical History o f the War,
pp. 125-128. The matter is of so much importance to all who may be called
on to treat such cases, that we will quote from opinions given nearly ten
years ago, and which will be found on page 126 of the volume just re-
ferred to.
' ' In regard to penetrating wounds of the abdomen, where there is reason to
suspect intestinal injury, it appears to me to be proper to enlarge the opening, if
necessary, to ascertain the nature and amount of injury, to remove foreign bodies
and extravasated matter, to employ sutures or ligatures where needed, and to cut
these short and return the injured viscera. The results of ovariotomy, of opera-
tions for strangulated hernia, etc., demonstrate that the dangers of opening the
peritoneal cavity and of handling the viscera have been greatly exaggerated.
Success in these operations must depend upon attention to minute details, such as
preventing lowering of the temperature, perfect cleanliness, etc. Especial care
should be taken to prevent even the smallest particle of fecal matter from escap-
ing into the peritoneal cavity, and to remove such as may escape. Ordinary
fecal matter contains immense numbers of microzymes. or minute organisms known
as bacteria, monads, micrococcus, etc.. which, if not the direct cause of putrefac-
tion, as seems probable, are, at all events, closely connected with that process.
The great danger in these operations probably arises from the sponges and water
used, and the less anything but the perfectly cleansed and disinfected hands of
the surgeon comes in contact with the peritoneal surfaces, the greater the chance
of success."
These, with the exception of the insisting on cleanliness, are substan-
tially the conclusions of Professor Dugas, and are given simply for the
purpose of strengthening his position, which we believe to be the only
tenable one.
Dr. Addinell Hewson's paper on the History of Nitrous Oxide Gas
as an Ancesthetic, and on the analgesic effects of rcqrid breathing, seems
to have elicited no discussion, although both the facts alleged and the in-
ferences drawn seem very doubtful.
Admitting that a certain amount of analgesia may, in some cases, be
produced by the means indicated by Dr. Hewson, it seems to us that the
results may all be accounted for by what we know of the power of expec-
tant belief or attention, and that the cyanotic phenomena are a result, and
not a cause.
1878.] Transactions of International Medical Congress, 1876.
165
The observations by Prof. Estlander on the Temperature of Osteo-
sarcoma are of interest to physiologists as well as pathologists, since they
point to an excessive local development of heat in rapidly growing parts.
They indicate a new possible means of diagnosis and prognosis, and it is to
be hoped that further data on this point will soon be furnished.
In the Section on Dermatology and Syphilography, the first paper is by
Dr. J. C. White, of Boston, on Variations in Type, and in Prevalence
of Diseases of the Skin in different countries of equal civilization, and it
forms an interesting contribution to the subject of medical geography.
Incidentally, we learn from it that there are but four specially trained
dermatologists in this country, over which fact each reader may lament or
rejoice according to his taste.
The article contains statistical tables of 10,000 cases of diseases of the
skin as seen in dispensary practice, and an attempt is made to estimate
differences in rate of prevalence, not only between America and Europe,
but between Boston, New York, and Philadelphia.
The conclusions from the discussion of these tables are as follows : —
' ' I. Certain obscure affections, the etiology of which is little, if at all, understood,
even in those parts of Europe to which they are mostly confined, may be regarded
as practically non-existent amongst us. Such are prurigo, pellagra, and lichen
exudativus ruber.
"II. Certain diseases directly connected with, and dependent upon poverty and
habits of personal uncleanliness, are less prevalent in the United States than in
those parts of Europe of which we have sufficient statistical information for com-
parison. Examples of this class are the animal parasitic affections especially.
" III. Some cutaneous affections of grave character, which are dependent upon,
or a part of serious constitutional disorders, are of less frequent occurrence, and
of milder type amongst us than in Europe in general, or those parts of it where
they are endemic. Lupus, the syphilodermata (?), and leprosy, are the most
marked instances of this class.
"IV. Certain disorders of the skin, especially those of its glandular systems,
and those connected more immediately with its nervous system, are apparently
more prevalent with us than in Europe. The most notable examples of the former
are seborrhoea, acne, and possibly the heat rashes ; of the latter, herpes, urticaria,
and pruritus."
The paper by Dr. G. A. Ward, on Verrugas, calls attention to a pecu-
liar disease endemic in certain parts of Peru, concerning which, we have
little definite information. The author thinks that the entire literature of
the disease is contained in an article by Yon Tschudi, unknown to him ; a
paper in a Lima newspaper, equally unknown; and an article by Dr. J. M.
Brown, U. S. N., who is also unacquainted with the literature of the sub-
ject, and we therefore think it proper to point out other sources of infor-
mation,1 and to supplement the paper a little by a compilation from these.
The verrugas, or warty disease, should, with our present knowledge, be
classed with the intertropical diseases known as pian, framboesia, or
yaws, the bobus of Brazil, the gallao of Guinea, the Aleppo button, etc.
Nothing definite is known as to its cause, for Yon Tschudi's statement
that it is due to the water, has been disproved by the observations of
1 Smith, A., Edinb. Med. and Surg. Journ., 1842, lviii., p. 67. Tschudi, J. J. Von,
Archiv. f. plrysiol. Heilk., 1845, iv., p. 378. Oest. Med. Wocbenschr., 1846, pamm,
and Wien. M. Wochens., 1873, xxii., p. 245. Salazar, Gaceta Med. de Lima, 1858,
Nos. 38, 39, and in Med. Times and Gaz., 1858, xvii., p. 280. Dounon, Etude sur la
Verruga, Arch. d. Med. Navale, 1871, vi., p. 255, 2 pi., also reprinted in Svo.
Browne, J. M., in Med. Essays by Med. Officers U. S. Navy, Washington, 1872, 8vo.
p. 335, and in Trans. Med. Soc. California, 1872-3, p. 173. Bourse, F., Arch, de Mel.
Nav., 1876, xxv., p. 353.
166
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[Jan.
Dounon, and Dounon's theory that it is malarial seems very improbable.
The warty tumours which characterize the disease arise from skin or
mucous membranes, and in structure, are to be classed as sarcomatous with
excessive growth of the epithelial layers ; they are very vascular, and often
give rise to serious hemorrhage, therein differing from molluscum, to which,
in appearance they are analogous. They may be readily confounded with
syphilitic nodes, as in one case mentioned by the author, the more so as
they are preceded by, or accompanied with osteocopic pains, and while
there is no evidence that this disease is connected with venereal, its en-
demicity and peculiarities will be of interest to the coming philosopher
who is to show the bearing of the law of evolution upon disease, and trace
the beginnings of syphilis. We find but one autopsy reported, in which
case M. Salazar found tumours in the stomach and liver analogous to those
on the skin, and also a large number of ulcers in the colon, but it is not
clear whether these were due to the disease. The treatment of the disease
most in vogue is by diaphoretics and diuretics, among which last Dr.
Ward mentions a new one, viz., an infusion of crickets' legs. We do not
find this mentioned by other writers, and there is a bare possibility that it
may have been confounded with the huajra, termed by the Spanish una
deguto (cats-claw) from the hooked thorns on the stalk, which is men-
tioned by Von Tschudi as the native remedy.
The accounts of the disease given by the various authors to whom
reference has been made in the foot note, are conflicting in many respects,
and careful and accurate investigations Avith photographs, temperature-
records, analyses of excretions, etc. etc., are much to be desired, for the
object of most of the writers thus far would seem to have been to arouse
curiosity rather than to satisfy it.
The paper on the Virus of Venereal Sores, its Unity or Duality, by
Dr. F. J. Bums te ad, is a clear and brief statement of existing knowl-
edge on this question. The old doctrine that all venereal sores are due to
a single specific syphilitic virus, is now generally abandoned in favour of
the teachings of Bassereau, that " some venereal sores are due to the
syphilitic virus, and others to a distinct specific virus known as the chan-
croidal," but within the last ten years a number of experiments in inocu-
lating the products of simple inflammation have been made, from which it
would seem that, under certain circumstances, pustules and ulcers may thus
be produced which are not distinguishable from chancroid. At first, it
was supposed that such experiments would only succeed on persons who
had been affected with syphilis, but this was disproved by experiments
made by Dr. Wiggles worth, of Boston, in 1867—8, and which are here
reported for the first time.
Pus from simple pustules of acne was inoculated on the forearm, pro-
ducing pustules, the matter from which was again inoculated with like
result. The same results were obtained by Kaposi, several years later,
and he was unable to discover any difference between chancroids and sores
thus produced. These facts are considered by Dr. Bumstead to explain
the results obtained by Clerc, Robert, Henry Lee, Pick, and others, who
found that true chancres were auto-inoculable after irritation, thus disprov-
ing one of the doctrines of the dualists. The same results have followed
experiments on syphilization, and for a time it was thought that they
might be accounted for by assuming the existence of a mixed chancre,
that is, of a sore which contained both the syphilitic and the chancroidal
1878.] Transactions of International Medical Congress, 1876. 167
virus. But from the results obtained from the inoculation of simple pus,
the author believes that : —
4,4 1. The virus of venereal sores is dual.
"II. Some venereal sores are due to the inoculation of the syphilitic virus.
' ' III. Other venereal sores are due to the inoculation of the products of simple
inflammation.
" IV. These two poisons may be inoculated simultaneously."
The third conclusion forms the main point of Dr. Bumstead's paper,
and this was not adopted by the Section, the general feeling being expressed
by Dr. Keyes, who said, that while no doubt pus from simple inflamma-
tions may produce ulcers, to say that these ulcers are identical with chan-
croid, was going too far. The conclusion adopted was that [" Science has
demonstrated that suppurative inflammatory] lesions which resemble [in
certain features, what we know as] chancroids, may be produced [on
various parts of the body] by inoculation with [simple] pus from various
lesions." We have inserted brackets in order to show that by omitting
two-thirds of the words, namely those included in the brackets, no loss is
incurred. The moral of which is the same as usual.
The papers by Dr. E. L. Keyes, of New York, and Dr. Charles E.
Drysdale, of Loudon, on The Treatment of Syphilis, agree in their
leading points, and illustrate the views of the most advanced syphilologists
of our day. Dr. Keyes disposes of two prevailing and dangerous errors ;
one, that a case of syphilis mild in the beginning, requires but little use
of mercury, and is not apt to be followed by tertiary, or even secondary
symptoms ; the other, that mercury is debilitating. As regards the first,
lie proves, we think, the danger of omitting continued mercurial treatment,
even in the mildest forms of syphilis. It is true that the outbreak of
tertiary symptoms after long abeyance (in one of the cases given, of thirty
3'ears) may be suspected as due to a fresh exposure, but aside from the
unquestionable rarity of a second infection, it is fair to suppose that the
reporter gives the entire history of the cases. Wilbouchewitch showed
that mercury in large doses reduces the number of the red corpuscles of
the blood, but Dr. Keyes's experiments with the hsemati metre, published in
this journal in January, 1876, and since extensively repeated, demonstrate
that in small doses it increased them, and is, in fact, a valuable tonic. The
argument upon this point is full and satisfactory.
Alfred Fournier has been thought the most strenuous advocate of long-
continued mercurial treatment, but Dr. Keyes even goes beyond that ac-
complished syphilographer. He administers mercury in minute doses for
two and a half to three years, and even longer, " and in all cases, if pos-
sible, until six months, and sometimes a year or more, after the appearance
of the last syphilitic symptoms." Dr. Drysdale advises a similar course
of treatment during at least eighteen months. Both writers concur in the
statement, which our own observations confirm, that this long-continued
mercurial treatment is quite compatible with the health and comfort of the
patients. Salivation is, of course, to be carefully avoided, and occasional
remittance of the remedy is followed by renewal of its beneficial effects.
Dr. Drysdale protests strongly against the use of mercury in soft sores,
as advised by J. Hutchinson and others, and we think justly. Ricord
and Bassereau should not have lived in vain.
Dr. S. Engelsted communicates an interesting account of the Meas-
ures adopted in Denmark to prevent the spread of Venereal Disease.
Encouragement is given to women to apply to the district surgeons for
1G8
Reviews.
treatment, and printed instructions " how to know the venereal disease,"
a-e distributed to prostitutes, soldiers, and others, that prompt treatment
may, as much as possible, be insured ; women found infected are required
to state, as well as they can, the names of those who have been in contact
with them, and such persons are invited to submit to treatment. In the
navy, before ships put to sea, the sailors are inspected. Discharged soldiers
are carefully examined, and if found diseased, are detained in garrison
until cured.
Systematic inspection of prostitutes is in force throughout the kingdom.
The examination is made twice a week ; the speculum is on all occasions
to be used. An objectionable feature seems to be that the certificate of
the woman's own physician, when she resides in private lodgings, may be
received as to her freedom from infection.
The results of the present law, enacted in 1874, cannot yet be correctly
estimated. There is, however, a notable increase in the number of women
brought under control who are not known as public women. This class,
notoriously the most dangerous, increased from 563 in 1873 to 1027 the
next year, and to 1340 in 1875. Dr. Engelsted has found mucous patches
nine times as common among women not regularly examined as among
the registered prostitutes. The mean of cases of disease for fifteen years
was 3.18 for the latter, and 29.04 for the former class.
The Danish " Social evil law" appeals to be humane and thorough in
its provisions, and its operations will be watched with much interest.
The paper by Dr. By ford, on the Causes find Treatment o f Non-puer-
peral Hemorrhages of the Womb, and the debate which followed it, are
of much practical interest. It seems clear that astringents given by the
mouth are of little use in such cases (gallic acid excepted), and that in
serious cases local applications only can be relied on. Dr. Goodell calls
attention to the value of cinnamon tea, or of cinnamon boiled in milk, in
some cases, and the tincture of cinnamon is used largely by Dr. Hodder,
of Toronto. The fact that such hemorrhages may be due to malaria, and
can be best treated by quinia, was alluded to by Dr. Campbell, and Dr.
Parvin advises vaginal injections of hot water ; in fact, each speaker
seemed to rely on a different remedy, from which we conclude that in
many cases almost anything will succeed, if rest and proper position be
insisted on.
The paper of Dr. Goodell, on The Mechanism of Natural and of Arti-
ficial Labour in Narrow Pelves, is characterized by Dr. Robert Barnes as
"the ablest paper that he had ever heard or read upon the subject," which
is enough to say as to the matter — while as to style it is perfection. Of
criticism on it we have none to make, and the conclusions of the author
form the only abstract which can be given. These conclusions are as
follows : —
"I. The unaided first-coming head and the aided after-coming head observe in
a flat pelvis precisely the same general laws of engagement and of descent. Hence,
version here means art plus nature.
"II. The forceps, however, applied in a flat pelvis, antagonizes more or less
with the natural mechanism of labour. Hence, the forceps here means art versus
nature.
"III. The aided and the unaided first-coming head observe in a uniformly
narrowed pelvis precisely the same laws of engagement and of descent. But ver-
sion violates these laws. Hence, the forceps here means art plus nature ; version,
art versus nature.
"IV. At or above the brim of aflat pelvis, the fronto-mastoid, or even the
fron to- occipital application of the forceps, interferes less with the moulding of the
1878.] Transactions of International Medical Congress, 1876. 169
head, and violates less the natural mechanism of labour, than the bi-parietal ap-
plication.
" V. ■ In the flat pelvis, the veetis aids the natural mechanism of labour, and,
therefore, meets the indications better than the forceps."
In his paper on the Treatment of Fibroid Tumours of the Uterus, Dr.
W, L. Atlee gives a classification of these growths which is excellent for
clinical and practical purposes. In treatment, ergot and muriate of am-
monia are the medicinal agents most relied on, and the rule is laid down
that tumours which are harmless to the patient should never receive
surgical treatment involving the least danger. In exceptional cases of
uterine fibroids, especially in extra-muscular tumours of the subperitoneal
variety, when they materially injure the health, and in some cases of
recurrent fibroids, extirpation of the uterus by abdominal section is con-
sidered warranted.
In the debate which followed, Dr. Barnes remarked very truly that
"we need not care so much about the successful cases as about the failures,
and also the reasons for the failures;" and Dr. Hodge also called attention
to the want of accurate statistics of results of operations for such tumours,
which are quite as desirable as for ovariotomy.
The views of Dr. Lusk, on the Nature, Origin, and Prevention of
Puerperal Fever, are based on an analysis of 1947 cases of deaths from
puerperal disease reported in the city of New York from 1868 to 1875,
and form a valuable contribution to the literature of this much studied but
still obscure class of diseases. Space does not permit of an abstract, and
the practical conclusions are of such importance, and so clearly expressed,
that we can only advise careful perusal of the whole paper.
The only point on which we have doubts is that the septic form of what
is commonly called puerperal fever is " intimately associated with the
existence in the tissues of minute organisms which form the connecting
link between puerperal fever and erysipelas and diphtheria." This may
be true, but the proof adduced by Dr. Lusk is not satisfactory, and some
of his statements are mere assertions without a particle of evidence, as, for
instance, that "the ductus thoracicus is the principal channel through
which the poison enters the blood."
Professor J. P. White, of Buffalo, furnishes a paper on Chronic Inver-
sion of the Uterus, which, as he says, simply brings forward facts and
conclusions already in a great measure laid before the profession.
Dr. White's method of reducing these inversions is well known, and in
his hands it seems to have been very successful. He does not believe that
excision of the uterus is ever necessary in such cases, and controverts the
opinions of Meadows, Barnes, Evory Kennedy, Donne, and others, as to
the difficulty or impossibility of reduction. There is no report of any
discussion upon his paper, so that we are in doubt as to whether his argu-
ments were considered1 conclusive, but must presume that this was the
case. Those who attempt to employ his method should, however, bear in
mind his warning, that in the period between the commencement and the
conclusion of the process of involution of the uterus, when it is undergoing
partial fatty degeneration, it is specially liable to rupture, and must be
handled carefully — or perhaps better still be let alone until from sixteen
to twenty weeks have elapsed from the time of delivery. It is also to be
noted that very considerable power of physical endurance on the part of
the operator is necessary to success, and herein may lie a part of the secret
of Dr. White's fortunate results.
170
R E V I E W S .
[Jan.
All the papers presented in the Section on Otology are interesting, at
least to the general practitioner; but we have space to notice but two of
them. The conclusions of Dr. Buck's paper on the Early Treatment of
Aural Disease ought to be borne in mind by every physician in cases of
the acute exanthemata in children. In all such cases there is a liability
to aural inflammation which often results in chronic otorrhoea — a disease
not only disagreeable, but dangerous. " Paracentesis of the membrana
tympani, if resorted to during the first few days of an acute attack, and if
not carried out too timidly, i. e., if a free incision be made, and not a mere
prick, is almost a sure preventive of the subsequent chronic disease/'
The second paper to which we would call attention is by Dr. C. J.
Blake, On the best Mode of Testing the Hearing of School Children,
and of Providing for the Instruction of Partially Deaf Children. Each
physician into whose hands the volume of which we are speaking may
come, will do well to bring Dr. Blake's remarks under the notice of those
engaged in the instruction of children with whom he may be acquainted,
for he may thus be the means of preventing a vast amount of mental and
in some cases of physical suffering on the part of the little ones under their
charge. Partial deafness in school children is much more frequent than
is usually supposed, and the teacher who for the first time tests the hear-
ing of his or her pupils in the manner proposed in this paper, will proba-
bly be much surprised at the results obtained, and may be troubled by the
remembrance of unjust punishments inflicted through ignorance of the
facts thus brought to light.
In the Section on Sanitary Science, the paper on Tlte Present Condition
of the Evidence concerning Disease Germs, by Dr. T. E. Satterth-
waite, of New York, is a fair presentation of existing theories on this
subject, and also contains some original observations made by the author
and Dr. Edward Curtis upon the nature of the poison of putrid liquids,
and on inoculations of diphtheritic membranes, which should be consulted
by all who are interested in this subject, and especially by those who pro-
pose to investigate it experimentally. The conclusions are negative, or
rather indefinite in character; but the experiments of Chauveau, Onimus,
and Sanderson, showing that in some infective diseases the contagious
matter is particulate, and may be separated from the fluids containing it,
are confirmed. It is very doubtful whether the morphology of the very
minute bodies to which such inquiries relate will ever be of much service
in deciding such questions ; and, if it is, photomicrography is the only
means of settling the disputes. We are disposed to think that it is to
chemistry, physiological tests, and the spectroscope that we must look for
aid in this, and that the microscope is useful only as a means of negative
proof.
The paper on the Vital Statistics of Buenos Ayres, by Dr. G. Rawson,
is a useful contribution to medical topography which calls for no special
comment.
Dr. J. M. Woodvtorth furnishes an article on Quarantine, which
favours that institution, and calls attention to the fact that it should em-
brace a system of port sanitation. He adopts Dr. Caldwell's explanation
of the origin of the name, viz., that it was derived from the forty days'
purification of Lent. Hecker's theory seems better: that the period of
forty days was adopted because that was supposed to be the limit of an
acute disease, a notion probably of Egyptian origin, and connected with
the forty days of the flood.
1878.] Transactions of International Medical Congress, 1876. 171
In the discussion which followed, Dr. Vanderpoel, of New York, re-
marked very truly that "Quarantine has killed more persons than it has
saved," and his belief as to cholera ''that, if the dejections can be disposed
of immediately, the risk of contagion can be prevented," seems to us to
be entirely correct, and to be the true* principle on which to act.
Following this comes a short notice on A Universal Pharmacopoeia , by
Dr. E. R. Squibb, which is a model of brevity and clearness. He shows
that the practical difficulties in the way of making such a Pharmacopoeia
are probably insurmountable at present, the most formidable one being
the providing proper means for its revision from time to time, and that
by the time progress in therapeutics has removed the obstacles there will
be little need of any effort in the matter.
The last paper in this Section is by Dr. Hunt, on The Relations of the
Pharmacist to the Medical Profession. It is not easy reading, requiring
a sort of mental translation, e. g., "This necessitates as a basic condition,
not only of success, but of all experimental investigation, a certified relia-
bility in the articles by which our therapy is tested or applied;" that is,
we ought to know that our medicines are what they profess to be ; but
when this is done, there will be found some sound advice. Whether the
remedy proposed, to consider pharmacy as simply one of the medical
specialties, and to attempt to obtain pharmacists who shall have a medical
education as a basis, and shall be recognized as physicians, is a practicable
one, we think doubtful ; but that the state of things cannot be much worse
in many places we have no doubt, and we welcome anything which looks
toward a change.
In the Section on Mental Diseases, the leading paper is by Dr. Kemp-
ster, on the Jlicroscopic Study of the Brain. It is a summary account
of the results of the examination of one hundred and fifteen cases, and was
illustrated before the Section by thirty-six photo-micrographs. In the
absence of these it is impossible to judge fairly of the merits of the paper,
and in fact it is to be hoped that the article is merely an abstract of an
extensive and properly illustrated treatise. INo histories of cases or ac-
counts of symptoms are given, so that the pathological appearances de-
scribed are severed from their proper relations, and can only serve as a
brief manual to indicate what other observers should look for. In inves-
tigations so uncommon and so difficult as those to which this paper refers,
it is necessary to have the data as well as the conclusions.
The article on the Responsibility of the Insane for their Criminal Acts,
by Dr. Isaac Ray, is excellent from his point of view, but it assumes
that the insane criminal should not be held responsible, which is the very
question at issue. Having assumed this, Dr. Ray goes on to prove that
no one but an expert can tell whether a man is insane or not, and that
good reasoning powers and a knowledge of right and wrong may exist in
a man who is so insane as, on the assumption just referred to, not to be
responsible. The logical conclusion, though not distinctly formulated, is
that in all grave criminal cases the decision as to the fate of the criminal
should be left to the managers of Asylums for the Insane. The now
prevalent distrust of the plea of insanity, which Dr. Ray deprecates, is a
very natural result of an examination of the cases in which it has been
used. What we had hoped Dr. Ray would have furnished was a discus-
sion of the responsibility question, in which theologic and sentimental
arguments should be omitted. What is the reply to the following thesis?
Punishment for crime by law is a substitute for private vengeance, and it
172
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[Jan.
is just in so far as it is expedient or useful. It is as expedient to rid the
world of the insane murderer as of the sane one, provided public senti-
ment permits it. It is not admitted that "responsibility" has any more
to do with the question than it has with disposing of a mad dog. or of a
criminal by birth and education who has committed murder. We say
provided public sentiment permits it, for if this sentiment is too greatly
shocked, more harm than good is effected. Why is it not quite sufficient
to leave the case to an ordinary judge and jury, and provide that no
expert be allowed to have anything to do with it?
This is the Benthamistic or utilitarian view of the subject. What is
the answer from the utilitarian standpoint ?
If it cannot be replied to without bringing in the so-called "moral law"
or "Divine law," then the matter does not belong to science, but to the-
ology. We will only add that, if all criminals are to pass into insane
asylums, which is the logical result of the responsibility doctrine, it is
much to be desired that the asylums should adopt hard labour as one of
their means of treatment, and endeavour to make such " irresponsibles"
pay their expenses.
Following Dr. Ray's paper comes one by Dr. Heches, on The Simu-
lation o f Insanity by the Insane, which furnishes the reductio ad absurdum
to the plea of insanity in criminal cases.
According to Dr. Hughes, the simulation of insanity is itself one of the
signs of insanity, so. that, if the criminal will only feign a little, he has a
sure means of escape. If the simulation is not detected, he is not held
responsible ; if it is discovered, it is a proof that he was insane, q. e. d.
It is no doubt true that the insane are influenced by ordinary motives,
such as fear, hope, love of approbation, etc., and that from such motives
they may either conceal their delusions or simulate a higher degree or
another form of insanity. This view has been expressed more frequently
than Dr. Hughes seems to suppose, and, indeed, is the basis of Dr. Con-
olly's subtle analysis of the madness of Hamlet. Dr. Hughes thinks that
criminals are often actually insane while feigning insanity to escape pun-
ishment, but the cases quoted scarcely support his position. He refers,
for instance, to the case of Lambert, who, in a paroxysm of rage, slew his
mistress and another woman. Dr. Parchappe, the official expert consulted,
held it to be a case of simulated unconsciousness or forgetfulness after
recovery from the paroxysm; Dr. Ray leans to the opinion that the in-
sanity was feigned. Dr. Hughes finds help for his theory in the following
pure assumption : —
"May not the simulation have begun before recovery had been completed,
after a realization, upon the part of Lambert, that he had committed heinous
crimes, from the penalty of which there appeared to him no escape except in
assuming unconsciousness of his acts?"
A hysterical lad who feigned contraction of the limbs, spasms, involun-
tary discharges, inability to move, etc., was detected in his imposture by
Dr. Bell, who thus describes the denouement : —
"The spell is broken; the feeble knees are made strong; the convulsed and
distorted visage is calm and smooth ; and the young deceiver goes forth clothed
and in his right mind."
This account would seem to decisively dispose of the case ; nevertheless,
Dr. Hughes still sees in it insanity simulating insanity, although it was
physical and not mental disorder that was feigned. Dr. Hughes does not
1878.] Burnett, The Ear; Anatomy, Physiology, and Diseases. 173
furnish any instances in point from the asylum under his charge, but
cites an unpublished case communicated to him by Dr. Workman, of
Toronto, which, however, does not justify the conclusion he draws. To
deny having been in the asylum, and to refuse to recognize the officers
whom he had previously known there*, may have displayed the prisoner's
cunning or sullenness, but cannot be regarded as a simulation of insanity.
The general argument is well summed up by Dr. Ray (in the discussion).
He says
; ■ Most of the insane know as well as other people that insanity is an excuse
for crime, and there is no reason why they may not strive to use it as such where
occasion calls, by feigning some manifestation of the disease over and above those
belonging to their own particular form of the malady. To do this requires no
more shrewdness and self-command than it does to conceal their delusions as they
sometimes do. The fact that they are already insane does not preclude the need
of simulation, for the well-known reason that the insane generally do not recog-
nize their own infirmity. To them the need of the excuse seems just as strong
and just as apparent as it would to others."
This is probably true, but Dr. Hughes's citation of cases in support of
it can be regarded only as surmises.
We have not alluded to a number of interesting papers, including all of
those presented in the Section on Ophthalmology, and this is simply due
to want of space. Those which have been noticed are fair samples chosen
almost at hazard, and we will conclude by saying that we have obtained
much pleasure and instruction from this volume, and we predict that any
one who will examine it carefully will be agreeably surprised.
J. S. B.
Art. XXI Tlie Ear; its Anatomy, Physiology, and Diseases. A
Practical Treatise for the use of Medical Students and Practitioners.
By Charles H. Burnett, A.M., M.D., Aural Surgeon to the Pres-
byterian Hospital, etc. With eighty-seven illustrations. 8vo. pp. 616.
Philadelphia: Henry C. Lea, 1877.
. As one of the evidences of general growth in a special department of
science, may be taken the demand for and production of the so-called text
books as distinguished from publications of a more limited character, the text
book being a work which shall serve both the purposes of systematic instruc-
tion and of occasional reference. To this class Dr. Burnett's treatise may
be fairly said to belong, since its comprehensive character gives to the oto-
logical student the preliminary instruction which he seeks, and to the
practitioner the latest contributions to the branch of medical science of
which the book treats.
In his preface the author says that in view of the great advances which
have, been made of late years in otology, and of the increasing interest
manifested in it, he has felt that the profession might welcome a new
work, which should present clearly but concisely its present aspect, and
should indicate the direction in which further researches can be most pro-
fitably carried on.
A detailed review of the work shows that this intention has been faith-
fully carried out, a due regard having been paid to the proportionate im-
portance of the various subdivisions of the subject.
174
Reviews.
[Jan.
Part I., comprising one hundred and forty-three pages, is devoted ex-
clusively to the anatomy and physiology of the ear, the remaining four
hundred and sixty-three pages being devoted to pathology and thera-
peutics. By this arrangement a proper sequence is given to the course to
be pursued by the student, the value of the work for occasional reference
remaining the same.
Part I. falls naturally into three sections, treating respectively of the
external, the middle, and the internal ear.
Chapter I. treats of the anatomy and physiology of the auricle, and
under the latter heading interesting extracts are presented from the works
of Darwin, Ludwig Meyer, J. Williams, Laycock, and others. The quo-
tations on the subject of the comparative functions of the auricle, and the
author's own observations on the resonant functions of this portion of the
ear, are of particular interest, especially the demonstration of the fact
that the auricle, in combination with the meatus auditorius, forms a reso-
nator of a more or less conical shape, closed at the bottom by the mem-
brana tympani, the special function of which is to strengthen by resonance
those waves of sound which possess a short wave length, certain portions
of the auricle resounding best to high partial tones, while other parts re-
sound best to the intermediate and low partial tones, thus insuring the
complete reception by the auditory nerve of all the partial tones which
compose any given sound falling on the auricle.
Dr. Burnett has observed that the region of the helix and its fossa
resound to the deeper notes, the anti-helix and its fossa to the interme-
diate notes, and that the concha resounds best to the high partial tones.
The conclusions at which he arrives from his experiments are, that the
concha is found superposed by nature upon the external auditory meatus,
in order to lengthen it, and that the external ear, as a whole, forms a
resonator for those tones having wave-lengths, the quarters of which are
represented by the various depths of the column of air contained by the
external ear. According to these observations, he considers it fair to
suppose that the entire apparatus of the external ear in all animals is
adapted to strengthening the sounds uttered by them and their species.
The absence of a developed auricle in birds not being, in his opinion, an
argument against its utility as a resonator in man, for the wave-lengths of
the high notes, which the former must both use and hear as a means of
intercourse with each other, are so short that they will resound perfectly
well in the shallow auditory meatus found in them.
While according a well-merited space to the consideration of the func-
tions of the auricle, the author has omitted to mention the subject of bin-
aural audition, especially interesting in reference to the appreciation of the
direction of the sound source, and which is treated of at length in a recent
monograph by Prof. Steinhauser,1 and in a report of experiments of a
character similar to those of Prof. Steinhauser, made by Lord Rayleigh.2
Chapter II. treats of the anatomy and physiology of the external audi-
tory canal. Concerning one function of the lining of the canal, the spon-
taneous removal of foreign bodies, the author quotes Voltolini's observa-
tions, and mentions also the fact of a progressive movement from within
outward, strongly suggestive of the growth of the nail, the mechanism of
this movement in the external auditory canal being as yet unexplained.
1 Anton Steinhauser. Die Theerie des Binauraben Horeus. Gerold's Solen, Wien,
1877.
2 Rayleigh. Determination of the Direction of a Sound Source. Nature, 1876.
1878.] Burnett, The Ear; Anatomy, Physiology, and Diseases. 175
Chapter III., anatomy of the membrana tympani, gives, in addition to
the usual description of its structure, the more recent investigations into
the conditions which result in the peculiar form of the membrana, and in
the production of that objective point which is so important a consideration
in its bearing upon the diagnosis of* affections of the membrana tympani
and middle ear, the light reflex. This chapter also includes the author's
investigations on the comparative distribution of bloodvessels in the mem-
brana tympani, showing a peculiar arrangement of vascular loops in the
dog, cat, goat, and rabbit, which is not found in man.
Under Section II., the middle ear, are included the tympanic cavity,
the Eustachian tube, and the cavity of the mastoid.
A considerable portion of the first chapter is devoted to the anatomy
and mechanism of the ossicles, and includes, taking the admirable experi-
ments of Helmholz as the starting-point, the later experiments of Politzer,
Urbantschitsch, Weber-Liel, Buck, and Burnett.
Chapter II., Eustachian tube and mastoid portion, gives prominence to
the subject of the constant patulence of the normal Eustachian tube, a
subject which has recently engaged the minute investigations especially of
German otologists. The author inclines to the opinion held by Riidinger
and others, that there is a small part of the normal Eustachian tube, the
so-called safety-tube in its upper part, under the cartilaginous hook, always
wide enough open to allow a recoil of air to occur from the drum cavity
if the drum-head is suddenly driven in, and also to permit a slow equali-
zation of pressure in the tympanic cavity from the pharynx, independently
of the act of swallowing; but this canal of safety is not wide enough to
allow constant ventilation of the drum cavity to go on.
In Section III. thirty-five pages are devoted to the labyrinth and
auditory nerve. The more or less elaborate monographs published,
especially within the past ten years, having for their subjects the
structure and functions of some part or the whole of this portion of the
organ of hearing, afford valuable material which has been judiciously
availed of for the compilation of the first chapter of this section. The
illustrations to this chapter, without which the student would find diffi-
culty in following any description of this complicated apparatus, are taken
mainly from the works of Henle, Waldeyer, and Riidinger. The clearness
of description is much increased by the progressive arrangement of the
subdivisions chosen by the author, the subject unfolding itself in natural
sequence, and affording a comprehensive idea of the structure of the
labyrinth with the least labour to the student. Indeed, clearness and
conciseness of description are characteristic of all of the anatomical por-
tion of the work. The subdivision of this chapter on the function of the
semicircular canals is a comprehensive review of the recent experiments
of Boettcher, Cyon, Mach, Brewer, Curschmann, Lowenberg, and Bern-
hardt, to whom, as the author says, belong the honour of having con-
ducted the most brilliant physiological experiments of modern times.
In Chapter II. a scheme of the relationship between the middle and
internal ear is presented which serves as a sketch of the subject-matter of
the preceding chapters, and tends to fix the more important points in
the relation of the several parts more clearly in the mind of the student.
Part II. opens with a description of the various instruments and the
methods of their employment in the examination of patients. Of the
various forms of specula employed, preference is given to the oval specu-
lum of Gruber as corresponding more nearly to the natural diameters of
176
Reviews.
[Jan.
the auditory canal. The usual objections are urged against the employ-
ment of Kramer's bivalve speculum, which is recommended, however, as
of use in anterior rhinoscopy. For the purpose of syringing the ear. de-
cided objection is made to the ordinary hard rubber ear syringe on account
of the danger of wounding the canal by pressure with the elongated tip.
The ordinary hard rubber male syringe No. 2 is recommended in prefer-
ence. A portion of this chapter is devoted to instructions in rhinoscopy,
and especially the examination of the pharyngeal orifice of the Eustachian
tube. This leads up to the description of the Eustachian catheter and its
use, and proper stress is laid upon the importance of avoiding any risk of
contagion by keeping an instrument for the especial use of each patient.
This is followed by a concise description of the inflation of the middle ear
by means of Politzer's air douche, preference being given to the original
method of Politzer over the methods more recently suggested by Gruber
and Lucae.
Chapter II. concludes the section on methods of examination with a
thorough description of the means to be employed in testing the hearing,
including directions for tests with the watch, tuning-fork, high musical
tones, and the voice, especial attention being given to the acoustic charac-
ter of vowel and consonant sounds as determined by the experiments of
Wolf and Appunn.
For tests with the watch, a stop-watch is preferred, as affording a means
of avoiding error on the part of the patient, the ticking of this form of
watch being under control of the surgeon. The limits of value of the
tuning-fork in tests of bone conduction, as more accurately determined by
the experiments of Lucae, are given at length, and the value of tests by
means of high musical tones in the differential diagnosis of diseases of the
middle ear is recognized. In speaking of the test by means of the voice,
allusion is made to the fact of the better hearing of low than of high tones,
which the author explains by reference to his experiments on the mecha-
nism of the ossicles, in which it has been shown that a deep note has the
advantage of high notes in cases of increased labyrinthial pressure. In
an increase of such pressure the stapes becomes more fixed, and it is on
this small bone that the vibrations begin to grow less as the pressure
within the labyrinth is increased. In such a case it is manifest that, if
vibrations from without are normally conveyed to the stapes, there they
must meet with hindrance in their endeavour to reach the labyrinth. Only
the more powerful sound waves are able to overcome this obstacle, and
force the stapes into to-and-fro-motions with the rest of the chain of ossi-
cles. It might be asked, therefore, according to the author, whether the
inability to hear high notes in some cases, while low notes are heard
nearly, if not quite, normally, could not be construed into a sign that the
stapes is impeded, either by undue pressure in the labyrinth, or by ca-
tarrhal fixation in the oval window. That the cause of such a peculiar
alteration in hearing probably does not lie in an undue tension in the
membrana tympani, appears from the well-known physical fact that the
tense membrane is more susceptible to vibrations of high notes. In test-
ing the hearing in cases of one-sided deafness, in addition to the tuning-
fork test proposed by Knapp, the author employs the following method for
a test with the voice : —
The affected ear being turned toward the speaker, and the opposite ear
closed, the ordinary test with the voice is made, and the limit of hearing
determined. Both ears are then closed, and the test repeated. If the
1878.] Burnett, The Ear; Anatomy, Physiology, and Diseases. 177
closure of the deaf ear causes no change in the limit of perception, it is
fair to conclude that whatever amount of hearing exists is not due to
passage of sound through the external auditory canal of the worse ear
turned toward the sound source.
If, however, stopping the deaf ear4urned toward the examiner still fur-
ther diminishes the hearing, the test should be repeated at decreasing
distances until the limit of perception is again reached ; this is the limit
of hearing by conduction of sound through the cranial bones, the difference
being the limit of aerial conduction by the external auditory canal.
Section II. describes firstly the organic defects of the auricle, including
plurality, abnormal position, and malformations, and the rare form of
arrested development resulting in congenital fistula of the ear. Cutaneous
diseases of the ear follow next in order, among which may be mentioned
the interesting case of a large horny growth from the upper and posterior
part of the helix, reported by Dr. Buck, and a case of herpes zoster of
the tragus observed by the author. The possible origin of the eruption is
not mentioned, however, and in this connection an interesting comparison
might be made with the case reported by Dr. Guerder,1 in which the
eruption was supposed to be the result of irritation of the chorda tympani.
Chapter II. treats of morbid growths, including cysts, angioma, vascu-
lar nsevus maternus, fibrous tumours of the lobule, for removal of which
the operation suggested by Knapp, a modification of the Mirault-Langen-
beck operation for hare-lip is advised ; an interesting case, in detail, of
glandular hypertrophy, epithelial cancer, and othematoma.
Chapter I. of Section III. is devoted to circumscribed and diffuse in-
flammation of the external auditory canal. In the former affection, in
addition to local applications, particular importance is attached to general
treatment, a point which is too often overlooked in dealing with this
slight but exceedingly troublesome affection. In diffuse inflammation
much importance is properly attached to the examination of the condition
of the middle ear, serious implication of this portion of the organ of hear-
ing being much more frequent than would ordinarily be supposed, and too
frequently overlooked until it forces itself upon the attention.
The rare diphtheritic form of diffuse external otitis unrnentioned by many
authorities is also described at length. In the early stages of simple dif-
fuse inflammation, free scarification is recommended, followed by syringing
with very warm water to promote bleeding. Moderately cool water would
better answer the purpose, as very warm water is often found of use in
controlling a copious bleeding. In addition to the several objections urged
against the general use of poultices, the author adds one which is worthy
of consideration, namely, the danger of implanting aspergillus.
Aspiration by means of Sigle's speculum is also recommended for the
purpose of favoring the exudation of the fluids accumulating in the der-
moid layer of the canal and membrana tympani.
For touching the small granulations which follow the more severe forms
of diffuse inflammation, monochloroacetic acid is strongly recommended
on account of the promptness of its action, its cleanness, and thoroughness.
The article on otomycosis reviews the numerous publications wThich
preceded, and especially which followed, the comprehensive work of Wreden,
together with an enumeration of the remedies advised, of which the author
gives the preference to alcohol, either alone or diluted with water.
1 Annates des Maladies de L'Oreille et du Larynx. Mai, 1877.
No. CXLIX Jan. 1878. 12
178
Reviews.
[Jan.
For the removal of foreign bodies the use of other instruments than
the syringe, unless absolutely necessary, is strongly deprecated, except in
the exceedingly troublesome cases of indurated epithelium which follow
desquamative inflammation of the canal.
Of the rare cases of foreign bodies impacted in the middle ear and
Eustachian tube the three cases reported by Mayer1 of foreign bodies in
the Eustachian tube are quoted; the occurrence of foreign bodies in the
tympanic cavity, in consequence of injudicious attempts at their removal
from the meatus, are unfortunately much more frequent.
Among the results of inflammation and injury, which subject forms the
third chapter, may be noted cholesteatomatous tumours, exostoses, and
osseous closure of the canal, including a quotation of Dr. Buck's valuable
paper on " ultimate forms of granulation tissue in the ear," and of Dr.
Matthewson's successful application of the dental engine to the removal of
osseous growths.
The occurrence of acute inflammation of the membrana tympani, as
distinguished from inflammatory processes in its contiguous structures, is
denied by many authors on the ground that this membrane is so intimate
in its structural relations with the external and middle ear that disease
originating in these parts may easily manifest itself, particularly in the
membrana tympani. Nevertheless the localization of inflammation in
either the dermoid or mucous coat of the membrana tympani is of suffi-
ciently frequent occurrence to make it a matter of convenience to recog-
nize such a condition as that to which the term acute myringitis is applied.
Under this heading, in the first chapter of section four, the author gives
a differential diagnosis between acute myringitis and acute otitis media,
which is of practical value. In acute otitis media there is found early in
the disease an mdrawing of the membrana tympani without thickening,
and the redness is limited to the manubrial plexus and the upper periphery.
In acute myringitis, however, the membrane becomes first rough and
evenly red all over, then thick and infiltrated, but not indrawn.
The pain in otitis media is much more severe than in acute myringitis.
In otitis media the secretion is copious and may be either mucous or puru-
lent ; in acute myringitis it is scanty and purulent, in the former the febrile
and constitutional symptoms are grave, in the latter such severe symptoms
are wanting. This chapter further includes the subject of ulcerations of
the dermoid layer of the membrana tympani, and of perforation of the
membrana flaccida, including the report of five cases of this comparatively
rare lesion, which came under the author's observation.
Section V., treating of the middle ear, comprises one hundred and
ninety-three pages. Of this space eighty-six pages are devoted to the
diagnosis and treatment of acute and chronic catarrh of the middle ear.
In addition to the detailment of the symptoms which are made familiar
by the prevalence of these affections, the author makes original observa-
tions which are worthy of note.
In speaking of the partial vacuum in the middle ear resulting from
closure of the Eustachian tube attention is called to the fact of the occur-
rence of blood extravasation, which may serve to account for some of the
rare cases of so-called otitis media hemorrhagica.
The symptom of ear cough has also been especially observed in con-
nection with a slight swelling of the faucial orifice of the Eustachian tube
during a head cold, the cough being induced by pressure upon the tragus.
1 Monatsclirift fur Ohrenheilkunde, IV., No. 1.
1878.] Burnett, The Ear; Anatomy, Physiology, and Diseases. 179
In his observations on the causation of tinnitus aurium the author accepts
the vascular theory of Dr. Theobald, the substance of the latter's auto-
graph being presented in extenso.
Under the head of double hearing two original cases are presented, one
of differential audition, one ear being normal, and the other a case of
sharping of all musical sounds during an attack of acute otitis media.
Well merited space is given to the subject of acute aural catarrh in
children, an affection to which far too little attention is paid, since, even
where it does not lead to more immediately serious manifestations of trou-
ble, it may lay the foundation of a more persistent form of progressive
disease, which shows itself later in life under conditions rendering it but
little amenable to treatment.
In addition to the usually recorded symptoms accompanying chronic
aural catarrh one peculiar symptom is mentioned ; this is an odour unlike
that of either true or false ozama pervading the majority of patients in
the mature stages of chronic aural catarrh, comparable to the odour of the
saliva, and due, in the author's opinion, to a disordered condition of the
follicles of the mucous membrane of the fauces, mouth, naso-pharynx, and
nose. The author's observations on implication of the sympathetic and
other nerves, published in Yol. IV., of the Archives of Ophthalmology
and Otology, are also here reproduced.
Under treatment is included a detailed description of the use of the
nasal douche, which is moreover recommended as a valuable adjunct to
the treatment of this form of disease of the middle ear, the author never
having seen a case of acute inflammation of the middle ear attributable to
its use. With regard to the efficacy which is claimed for this means of
cleansing the naso-pharyngeal space, there can be no question ; with regard
to its safety, however, as concerns the integrity of the middle ear there is
much and well authorized rebutting testimony.' Excision of the tonsils is
regarded as rarely, if ever, necessary, for the relief of hardness of hear-
ing or deafness, simply because the altered function of hearing is in no
way dependent on the tonsillar enlargement. When associated with deaf-
ness, their enlargement is to be regarded simply as a symptom of a catarrhal
condition, which has also brought about alteration in the glandular struc-
tures. Excision is worse than useless. This opinion agrees in the main
with the observations of the late Wm. Harvey, of London, who, however,
advocated the excision of the enlarged gland, on the ground that its per-
sistence in the enlarged condition presented a larger surface for the per-
petuation of the catarrhal disease in addition to the mechanical irritation
to which it might give rise.
Of operative procedures upon the membrana tympani and within the
middle ear, especial mention is made of the attempts to maintain a per-
manent opening in the drum-head and of the operation for tenotomy of'
the musculus tensor tympani. As concerns the latter, the author gives
a full account of the practices and opinions of various writers who have
accepted this operation as a valuable contribution to aural surgery, or
have practised it for the purpose of testing its merits, withholding his
own opinion on the just ground of a want of personal experience as to its
efficacy. The application of electricity to the organ of hearing concludes
the third chapter. In regard to the intra-tubal electrization of Weber-
Liel, the improvement is considered to be due rather to the mechanical
effect of the passage of the instrument, a silver wire used as a rheophore,
through the Eustachian tube, than to any action of the electric current..
180
Reviews.
[Jan.
Under the heading, "Unusual Diseases of the Middle Ear," are included
cases of objective snapping noises in the ear, due, according to Politzer
and Lushka, to spasm in the palatal muscles whereby the anterior wall of
the mouth of the Eustachian tube is suddenly drawn away from the pos-
terior wall. This explanation of the peculiar symptom is substantiated
by the author in the account of a peculiarly interesting case of the kind
coming under his own observation. The extravasation of blood into the
tympanum in Bright's disease, as observed by Schwartze and Buck, and
the disease described by Roosa under the name otitis media hemorrhagica,
are also noted.
The observations of Schiitz on tubercular disease of the ear. and of
Wendt on cholesteatoma are also accorded due recognition.
Under acute and chronic purulent inflammation of the middle ear, in
describing the objective appearances accompanying the former, mention is
made of a point of diagnostic value, namely that the presence of pus in the
tympanum invariably causes bulging of the membrana tympani, while an
equal amount of mucus usually does not produce a similar effect. This is
accountable for by the fact that mucous accumulations are usually accom-
panied by a greater or less degree of thickening of the mucous coat of the
membrana tympani, the resistance of the membrane being thereby in-
creased. In the treatment of acute otitis media local depletion, or even
if this should be for any reason impossible or insufficient, general bleeding
is advised ; the warm water douche has seemed in some instances to bring
about a resolution of the inflammation, and paracentesis of the membrana
tympani may be employed even before secretion in the tympanic cavity
has appeared, with the result of relieving the congestion and tension of the
parts. In the treatment of chronic purulent inflammation of the middle
ear, while due regard is had to the influence of thorough and frequent
syringing, the more heroic measure of forcing fluid through the Eustachian
tube as recommended by Van Millingen and Hinton is deprecated. Clean-
liness and perseverance are laid down as cardinal and effective virtues in
the treatment of this often discouraging form of ear disease. Of astrin-
gents the preference is given to zinc, silver, and alum. The possible con-
sequences of chronic purulent disease of the ear are given, as permanent
deafness, epileptiform and other nervous manifestations, granulations and
polypi, ulcerations of the tympanic mucous membrane with its possible
train of periostitis, ostitis, caries, necrosis, and fatal implication of contigu-
ous organs. Of the more common complication, granulations and polypi,
the following classification is made : 1. Mucous polypi. 2. Fibromata.
3. Myxoma. 4. Angioma ; the two latter varieties having been observed
but once, myxoma by Steudener, and angioma by Buck.
For the removal of the more common growths, preference is given to
the wire snare ; and for subsequent application to the seat of the excised
growths, nitrate of silver, chloro-acetic acid, and chromic acid are advised.
Caustic potash, in some cases a valuable escharotic, is not included. In
describing the symptoms and course of that always possible complication
of purulent otitis media, mastoid disease, well merited reflections are made
on the not uncommon neglect of observation of the symptoms which mark
the local character of the trouble, and which, if promptly recognized,
would lead to effective measures for the relief of what is often vaguely
called a cerebral affection.
Diseases of the internal ear, to wdiich Section VI. is devoted, include
anomalies of formation, ancemia, hyperemia and inflammation, traumatic
1878.]
Forensic Medicine and Toxicology.
181
injuries, the results of cerebro-spinal meningitis, and disease of the laby-
rinth in consequence of syphilis and typhoid fever ; considerable space is
also accorded to aural vertigo from chronic catarrh of the middle ear, and
from secondary inflammation of the Jabyrinth.
The subjects of deaf-mutism, and of the relief and education of partially
deaf children, form the seventh and last section of a work which is a valua-
ble contribution to the otological library, because it presents in a readily
available form the information which is the basis of the first study of the
subject of which it treats, and also the most recent observations in anato-
my, physiology, and therapeutics. The author's comprehensive knowl-
edge of the literature of his special subject has enabled him to glean from
a large mass of available material, at the same time enriching the work
with his own original observations. C. J. B.
Art. XXII — Forensic Medicine and Toxicology. By W. Bathurst
Woodman, M.D., F.R.C.P., Assistant-Physician to the London Hos-
pital, etc. etc., and Charles Meymott Tidy, M.B., F.C.S., Professor
of Chemistry and of Medical Jurisprudence and Public Health at the
London Hospital, etc. etc. 8vo. pp. 1083. Philadelphia: Lindsay &
Blakiston, 1877.
The appearance of another large work from the press, Avith the above
title, so soon after the recent publication of the new and enlarged editions
of Dr. Taylor's Principles and Practice, and his Manual of Medical
Jurisprudence, Prof. Guy's Forensic Medicine, and Wharton and Stille's
Medical Jurisprudence, certainly argues favourably for an increasing in-
terest in, and an extended cultivation of this highly important branch of
science — important alike to medicine and law. Hitherto, neither of these
professions, at least in this country, seem to have fully realized the proper
status which this subject should occupy in their respective departments.
We need hardly remind the reader of the well-known fact, that in very
few of our medical colleges does medical jurisprudence receive even a pass-
ing complimentary notice in the curriculum of study; and what is, per-
haps, even more remarkable, in many of our law schools, it is either en-
tirely ignored, or, as in the case of the Law Department of the University
of Pennsylvania, while the title of this professorship appears among the
others on the programme, the student is informed that attendance on the
lectures of that branch is entirely optional, and that it is not required for
his law degree ! Of course, this affords but a very questionable encourage-
ment to the student of law to interest himself in a branch of science, which
is necessarily so interwoven with criminal law ; and the consequence has
been that our young lawyers, as a rule, avoid this department of their pro-
fession altogether, as a subject distasteful to them, from their ignorance both
of its principles and practice. We may hope, however, that this preju-
dice on the part both of college authorities and students will soon be dis-
pelled, and that they will be aroused to a proper appreciation of the true
merits of the subject.
The work before us is the joint production of two gentlemen, who, from
their hospital and professional connections in London, and from having
182
Reviews.
[Jan.
been pupils of the late Dr. Letheby, have enjoyed excellent opportunities
for qualifying themselves for the task that they have undertaken; and
from a somewhat careful perusal of its pages, we take pleasure in bearing
testimony to the general fidelity with which this has been accomplished.
The introductory chapter contains a summary of hints to medical experts
on the importance of a due acquaintance with the facts of the case in which
they are to testify, the proper mode of giving their testimony, and the fees
to which they are entitled. The authors say that a professional witness
"is not bound in a civil trial, nor always in a police court, to give evidence
unless paid his necessary expenses." We are glad to be told authorita-
tively that such is the rule in Great Britain. In our own country, as the
expert unhappily knows, this is not the case, except he is called outside of
his own State, when he may make his own terms. But within the borders
of his State (at least such is the law of Pennsylvania), the expert is com-
pelled, in a criminal trial, to obey the mandate of a subpoena from either
the prosecution or the defence, no matter if it takes him hundreds of miles
from home, and detains him from his lawful business for days ; and this for
a paltry compensation, less than that of a common day labourer! This we
deem to be a grievous wrong, and one which confessedly requires redress.
The rules laid down in another chapter for the examination of bodies
found dead are judicious, and, in the main, sufficiently explicit. The
directions given for removing the stomach and preserving it are not quite
as precise as, we think, the importance of the subject demands. We refer
particularly, in a case of suspected poisoning, to the necessity of keeping
this organ and its contents in a separate vessel, apart from other organs,
for the reason that the poisonous solution would readily escape, by imbibi-
tion, through the walls of the stomach, and contaminate any other organ
in contact with it, as, for instance, the liver, kidney, or spleen, and thus
give rise to a false inference on the part of the analyst in relation to the
absorption of the poisons into the organ during life.
Nothing is said upon the subject of determining the time of death from
the aspect of the body — a very important medico-legal question, and one
which at times occasions no little difficulty in a trial for alleged homicide.
This question, of course, turns chiefly upon the changes produced by putre-
faction ; and this latter again is dependent upon a variety of contingencies.
This point constituted an important item in a recent trial for murder at
Norristown, Pa. (Com. v. Wahlen, Sept. 1877), where the question was
as to the identification of a body, which had been partially exposed for
upwards of four months.
Chapter IV. commences the important subject of Poisons. In it, a clear,
general resume is given of their modus operandi, and the causes modifying
their action. Under the latter head, too slight a notice is, we think, be-
stowed upon the effect of the combination of poisons, or the antagonism
of poisons, although, in a subsequent chapter, the authors make a passing
allusion to it. This is a subject which has, of late, attracted considerable
attention, from the experiments of Fraser, Bennett, Brunton, and others.
An omission under this head, on the part of the authors, should not. we
think, be passed by unnoticed; we allude to the Post-mortem Imbibition of
Poisons; or the fact that the introduction of a poisonous solution into a dead
body, either by the stomach or rectum, or hypodermically, will cause an
osmosis of the poison into the adjacent organs and viscera, e.g., the liver,
spleen, kidneys, heart, and lungs; and by contamination, these organs
might readily give rise to the suspicion on the part of the toxicologist.
1878.]
Forensic Medicine and Toxicology.
183
who subsequently discovered the poison in them, that death had been actu-
ally caused by poison ; whereas this had been introduced after death, and
for the sinister purpose of fastening suspicion on an innocent person. On
page G8, a very brief reference is made to this subject, and Orfila's expe-
riments are alluded to ; but the quotation made does not properly apply
to the point in question, but has reference simply to the extension of in-
flammation to contiguous organs. Its important medico-legal bearing will
be apparent on a moment's consideration.
The timely advice is given in all cases of suspected poisoning, and espe-
cially when the patient survives, never to omit the chemical examination
of the urine. Without such examination, we think that the charge of
poisoning cannot be sustained, unless there should be some other positive
evidence of its administration.
The appearances after death by poison are stated with sufficient accuracy
and detail, and need no special notice here; as also the diseases that simu-
late poisons.
The chapter on Systematic Chemical Analysis contains many excellent
hints for the toxicologist. We notice, however, one or two inadvertences.
Thus, in describing the distillation of the suspected liquid, it is stated very
properly that "if free hydrocyanic acid be present, it will be found in the
distillate" without the previous addition of an acid to the contents of the
retort, "but, if the contents were alkaline before distillation, it (the hydro-
cyanic acid) must have been present in the original liquid as a cyanide."
This seems to imply that the hydrocyanic acid would be found in the dis-
tillate under the latter condition also, which is not the fact, since the addi-
tion of an acid would be first necessary in order to decompose the cyanide.
Again (p. 81) there is some looseness in the description of the method of
separating the alkaloids, as regards the proper solvents to be employed —
ether being recommended for the trial testing, and subsequently chloroform
for their more complete extraction. Here it 'seems to have escaped the
authors' notice, that morphia is scarcely at all soluble in chloroform, while
it is very soluble in ether.
The remarks upon the importance of obtaining by our tests — especially
in a capital case — more than "questionable or doubtful reactions," are
much to the point, and deserve the careful attention of the toxicologist ;
as do also the conclusions about obtaining "microscopic sublimates, which
we admit are as exquisitely beautiful, as they are, in our opinion, totally
unfitted for practical investigations These are all very well as
confirmatory tests, but nothing more. To build evidence entirely upon
them in a criminal case is dangerous in the extreme" (p. 84).
We should have liked to see a timely caution thrown out to the toxicologist
in relation to his attaching too much importance to the mere colour of his
precipitates as proof of poison. The books abound in illustrations of this
fallacy. Another point which is not brought out with the clearness which,
in our opinion, it deserves, is the absolute necessity (in cases of metallic
poisoning) of extracting the metal as the only proper, unanswerable proof
of the alleged crime. This last point is, we believe, now insisted on by
all modern authorities.
The description of the individual poisons is clear and concise, yet, at
the same time, embracing all that is essential to the subject ; and, what
adds not a little to its value, there is appended to each section a list of
cases, comprising the dose, symptoms, and post-mortem appearances, to-
gether with the authority for each case. Under the head of Arsenic, we
184
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[Jan.
think an unnecessary caution is given — "in exhumation crises, to examine
some of the soil of the cemetery, which may contain arsenic from its geo-
logical constitution" (p. 155). We had supposed that the idea of cemetery
arsenic, which was so prevalent in Orfila's day, had become obsolete, and
had ceased to be entertained by modern authorities ; since it is now well
known that arsenic never exists in the soil of cemeteries in a soluble state,
and, therefore, the fear of the contamination of a corpse by that means is
altogether groundless.
In the chemical examination of the tissues for arsenic, no mention is
made of the interesting fact first noticed by M. ScolosubofF, of Moscow,1 that
in dogs (and presumably in man) poisoned by this substance, the brain
and spinal marrow are found, after death, to contain a much greater amount
of the poison than even the liver. This is a highly suggestive observation,
and it deserves to be remembered by the toxicologist in his post-mortem
search for arsenic, and, indeed, for other metallic poisons.
In the chapter on Strychnia, the authors, when enumerating the differ-
ent antidotes recommended for this poison, omit all notice of bromide of
potassium, an article that has been found to be very efficacious in many
instances. Neither is any allusion made to atropia, which, according to
Mr. S. Buckley,2 exerts a true antagonizing power over stiychnia, and
which proved an efficacious antidote in a case related by himself.
Under the heading of Hydrocyanic Acid, the authors very properly
caution against the addition of an acid to the organic liquid before distil-
ling it, since otherwise (unless it were distinctly alkaline) "it might be
urged that the prussic acid obtained in the distillate was the result of the
decomposition of sulphocyanide of potassium, which is a normal constituent
of saliva" (p. 412). In the celebrated trial of Dr. Schceppe, at Carlisle,
Pa., in 1872, it was strongly and successfully urged by the defence that
the trace of hydrocyanic acid alleged to have been found in the stomach
of the deceased, might very properly be ascribed to this very circumstance,
inasmuch as the analyst had before distilling added sulphuric acid to the
suspected substance, which, it was claimed, had contained prussic acid in
the free state. This important toxicological fact has since been distinctly
recognized in the last editions of Taylor, and of Wharton and Stille.
The chapter on the Examination of Hairs and Stains contains some
excellent remarks on the method of identifying hairs of different origin,
and various kinds of fibres, such as linen, cotton, silk, and woollen, when
these are found adhering to a weapon smeared with blood, in a case of sus-
pected murder. Here, of course, the aid of the microscope must be in-
voked, and often with the happiest results. A number of very good
enlarged wood-cuts serve to illustrate this subject the better.
We next have described the modes of examining Seminal and Blood-
stains. In regard to the former, while the assertion is undoubtedly correct,
that we should "under no circumstances admit a stain to be seminal, unless
you discover complete spermatozoa," we must, on the other hand, not for-
get the fact so distinctly pointed out by Prof. Casper, and confirmed by
others, that spermatozoa do not at all times appear even in healthy semen.
Hence, while the presence of the zoosperms is positive proof of the presence
of semen, their absence is not necessarily evidence of the contrary; although
in a medico-legal case, it would be unsafe to urge this last argument.
Blood stains are treated of with sufficient accuracy and detail, especially
1 Archives de Physiologie, No. 5, Aotit et Septembre, 1875.
2 Edin. Med. Journ., Sept. 1873.
1878.]
Forensic Medicine and Toxicology.
185
in relation to their spectroscopic examination. This method of investiga-
tion has, within the last few years, attracted considerable attention on
account of its extreme delicacy and alleged accuracy under proper restric-
tions. We regard it as of great value as a corroborative test ; but we think
it should never be relied on exclusively as evidence, especially in a capi-
tal case. It is especially valuable in detecting old blood-stains. Thus,
we are told that "Mr. Sorby has been able to identify blood by the spectro-
scope after forty-four years ; and Dr. Letheby and one of the authors after
thirty years." The chemical examination of blood-stains is described very
concisely, — the guaiacum process of Dr. Day apparently not ranking so
high in the estimation of the authors as the spectroscopic. It is, however,
one which has received the unqualified sanction of Dr. Taylor and others,
as being specially adapted to the detection of old stains. Our own expe-
rience fully indorses its value in medico-legal investigations.
In relation to the microscope, as applied to identify blood-corpuscles and
blood-crystals, the authors' description is clear and satisfactory; and as to
the possibility of thus distinguishing between human and other blood, a
passing notice is given of the important discovery, by our townsman, Dr.
J. G. Richardson, of the means of identifying human blood-corpuscles by
the use of high powers of the microscope. But, we think, that scarcely
sufficient emphasis is here given to this valuable medico-legal fact.
Chapter XX. discourses, at considerable length, on the subject of Life
Insurance in its different medico-legal bearings; and incidentally to this,
various other topics are treated of, such as dentition, variations in the
pulse, effects of factory labour, result of vaccination, etc., together with
modes of death.
Personal Identity of the Living and the Dead next claims our attention — a
subject of much interest, and often of great practical importance, as evidenced
by the late famous Tichborne case. The points specially referred to in the
identification of the skeleton are age, sex, and height. The usual tables of
measurements are given, as those of Sieveking, Sue, Orfila, Humphry,
Guy, and Taylor. And here the caution may not be superfluous, not to
give too positive an opinion as to identity merely from an inspection of the
bones, unless there exists some marked peculiarity, either congenital or
acquired. As to the identification by the skull alone, we think that this
is possible only in exceptional cases, as, for instance, from the state of the
teeth and jaw, or from some particular mark or scar. Neither do we be-
lieve that, as a general rule, the cranium alone will enable us to distinguish
the particular race of the individual; for, although there are very marked
differences between the typical skull, for instance, of a Caucasian and a
negro, such as we find them depicted in the books, yet numerous instances
occur where the lines of demarcation are so finely drawn, and are so gradu-
ally shaded off, that it would be hazardous to venture too positive an
opinion in an important case.
The questions relating to Impotence and Sterility, which form part of the
subject of Chapter XXII. , occasionally assume considerable importance in
courts of law, as in applications for divorce based upon these grounds ; and
the aid of the physician is required to decide them. They are discussed in
the work before us with sufficient precision, and we notice nothing requir-
ing particular comment.
In alluding to the Signs o f Pregnancy (Chap. XXIII.), the proper dis-
tinction is drawn between the uncertain and the certain signs. Among
the former are classed morning sickness, cessation of the catamenia, quick-
186
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[Jan.
ening, mammary changes, enlargement of the abdomen, and kiestine in the
urine. Among the latter bal/otement, changes in the os and cervix uteri,
and, above all, the sounds of the foetal heart, distinctly heard. The latter,
as we all know, is really the only positive, unequivocal sign. No allusion
is made (and probably it was scarcely needed) to the difficulty of diagnos-
ing between pregnancy — especially in the earlier stages — occurring in those,
fortunately rare, instances of complete retroversion of the uterus, and a
uterine tumour with the same complication. From experience, we know
this to be not always an easy matter.
As regards the evidence afforded by the corpus luteum of a previous
pregnancy, or of an abortion, the authors adopt the sound and conservative
opinion ; not committing themselves as to its being a positive sign ; but. at
the same time, they state very distinctly the differences between the corjms
luteum of pregnancy and that of menstruation.
The very interesting question of Protracted Gestation in its relation to
legitimacy receives a candid examination ; the result of which, as derived
from numerous observations of undoubted authority, and drawn also from
the argument from analogy of the lower animals, is that occasionally in the
human female the period of gestation may be protracted to forty-one, forty-
two, and forty-three weeks or even beyond this limit from the period of
impregnation. This accords with the decisions of the courts both in
Europe and the United States. The French law, by the Code Napoleon,
allows 300 days ; and the Prussian law 302 days; The English law fixes
no period. In the United States several decisions have been given ; by one
of which paternity was allowed in a case where the period of gestation must
have extended to 313 days (Com. v. Hoover). This case was argued
before the late Judge Ellis Lewis, who charged the jury in favour of the
prosecution (vide Am. Journ. Med. Set.. October, 1846 ; with a note from
Prof. Atlee, in which he mentions two eases within his own practice
where the period of gestation was about a year). The laws of Pennsyl-
vania allow the extreme limit of twelve months for the legitimacy of a
child.1 This is undouotedly stretching the mantle of charity to its utmost
capacity ; and we would venture the remark that in all such exceptional
cases it behooves the female to exhibit the most unexceptional proofs of a
previous virtuous character. In the celebrated Gardner Peerage Case
the illegitimacy of the child, born 312 days after the husband's departure,
was affirmed by the House of Lords, not, however, so much on the ground
of the protracted gestation, but rather because of the known adultery of
the wife.
There is nothing requiring special notice in the description of the Signs
of Delivery. As is well known, many of these disappear very soon after
the recovery of the female, so as to be scarcely, if at all recognizable except
in a multiparous woman. This is notably the case in the changes under-
gone by the uterus. If, however, death occurs very soon after delivery,
the diagnosis becomes, of course, easy; the size and general aspect of the
uterus, together with the corpus luteum, removing all doubt. In the mul-
tiparous female the changes in the conformation and feel of the uterus con-
tinue even for years after delivery, by means of which a diagnosis may
often be made, especially when the question is between a multiparous and
a nulliparous uterus. Dr. Tyler Smith mentions the case of a lady and
her maid who were burnt to death together in a hotel in London. Their
bodies were so multilated as to render any recognition by external signs
1 Wharton and Stille's Med. Jurisp.; vol. ii. p. 52.
1878.]
Forensic Medicine and Toxicology.
187
impossible ; but the lady had borne a numerous family, and the identity
of her bodv was ascertained from the condition of the uterus. (Man. of
Obstet., p. 38.)
The succeeding chapter treats of JIalpraxis : but it appears to us to be
somewhat strangely out of place here, being wedged in between two other
chapters which are devoted to obstetrical jurisprudence. We must never-
theless make a few observations upon it in this position. As the authors
remark, fractures and dislocations constitute by far the most frequent causes
for actions for malpractice. Some timely cautions are added, to which it
would be well for surgical practitioners especially to give heed. We find
no allusion made to one particular cause of shortening of the leg, which,
though comparatively rare, does nevertheless sometimes occur, namely,
severe contusion of the hip, resulting in absorption of the neck of the femur,
so as to shorten the limb very markedly, and that without any fracture or
luxation. Of course, there need be no mistake in the diagnosis of such a
case ; but the mere shortening of the limb, after recovery, might very natu-
rally suggest a previous fracture ; and in our own experience it was, on one
occasion, actually made the ground for a suit for malpractice, based upon an
alleged error of diagnosis and treatment. The real state of the case was.
however, satisfactorily established, and the charge, which was doubtless
brought for extorting money, fell to the ground.
Malpractice in obstetrical cases has reference usually to rupture of the
uterus, or of the perineum (resulting in recto-vaginal fistula), fatal hemor-
rhage, and the communication of the poison of puerperal fever or syphilis
by the accoucheur. "We say nothing here of those cases, fatal or other-
wise, connected with the performance of criminal abortion, which properly
come under another head. We may dismiss the subject of medical mal-
praxis with this single remark — and it covers the whole ground of the
accusation — that the charge can never be sustained against the practitioner,
provided he can satisfactorily prove that he lias bestowed upon the case
the proper amount of skill and attention. In other words, ignorance and
negligence form the only legitimate grounds for the charge.
The next subject that claims our notice is Rape; and only one or two
points will require attention. Among the signs of virginity, the authors
regard an intact hymen as the most positive. This is undoubtedly correct.
According to Devergie, a ruptured hymen may be considered as evidence of
defloration in 999 cases out of 1000. This perhaps may be going a little too
far, since cases have been reported where this membrane has been destroyed
in early life by disease or accident. But the converse of the proposition
certainly cannot be maintained, namely, that an unruptured hymen is
always the sign of virginity; since we know from the observations of
Parent-Duehatelet, and others that the membrane has been found sound
in prostitutes, and that even pregnancy has occurred in women with an
unruptured hymen, so that the membrane had to be divided by the
accoucheur before delivery could be accomplished.
When speaking of rape upon young children, the authors are careful
to draw attention to the frequency of infantile leucorrhoea among children
of the lower classes, and living under bad hygienic influences. It is ex-
tremely important not to mistake a case of this kind for one of alleged
violation, as the muco-purulent discharge and the swelling of the parts
might mislead an inexperienced examiner. It has not unfrequently hap-
pened that a false accusation has been preferred against a perfectly inno-
cent man, supported by the above-mentioned appearances, and prompted
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by sinister motives, such as the extortion of money, or revenge. Casper
mentions several cases of this character.
In relation to the commission of rape upon a female while under the
influence of anaesthetics, the very important question comes up whethee a
woman, anaesthetized by ether or chloroform, and probably under the
influence of an erotic dream, might not really suppose that she had been
violated by the practitioner, whom she had seen by her side only a few
minutes before losing consciousness? And might she not, impelled by
some motive known only to herself, actually bring a criminal charge against
an innocent man, based upon such an hallucination ? We deem this to be
no mere fanciful idea. There is abundant testimony to show that females
while under the influence of ether do sometimes experience amatory sen-
sations ; and their own confessions fully justify the position here assumed.
Some of our readers will doubtless recollect an important case of this kind
which occurred in this city some twenty years ago, in which a criminal
charge was preferred against a highly respectable dentist by a female
patient, who had been put under the influence of ether. Upon the woman's
own evidence solely, and without any medical examination, the defendant
was convicted, and sentenced to imprisonment. There were circumstances
connected with this case that certainly did not justify this conviction ; and
we hold it to be derogatory both to justice and medical science to presume
to arrive at a conclusion, in a case of the above character, without a pre-
vious careful medical examination. (For a critical analysis of this case
see Wharton and Stilffls Medical Jurisprudence, vol. ii. p. 201.)
In Chapter XXVI. we have the important topics of Criminal Abortion
and Infanticide presented to us. Under the former, the authors express
their just indignation that " in modern times our unjust laws and more
unjust social customs, by making the woman bear almost all the burden
of support and the whole of the shame of illegitimate children, have
tended to make some medical men look on this crime rather as a charita-
ble action, done to shield a suffering woman, than as it really is a foul
and unnatural crime, not only against society, but against a helpless, inno-
cent and defenceless life." (p. G63.)
Did space permit, we might dwell at some length on the frightful and
seemingly increasing prevalence of this crime in our own country, not
only in cases of illegitimacy, but even among so-called reputable and
fashionable married members of society, who do not hesitate to resort to
the arts of the foeticide, instigated solely by the selfish desire to avoid the
expense and inconvenience of an increase in their family !
The usual array of drugs popularly employed for this vile purpose is
mentioned, without, however, assigning any special pre-eminence to ergot.
Our own opinion has always been that, if there is any article of the materia
medica that can claim a specific power over the impregnated uterus, that
substance is ergot. A proper caution is given to distinguish between a
mole, or hydatidiform degeneration of the chorion (which is always an
evidence of pregnancy) and certain bodies which are occasionally expelled
from the unimpregnated uterus, such as dysmenorrhoeal casts and clots.
The description of the foetal heart and lungs is accurate, as is also that of
the changes occurring in both of these orgaus after respiration has been
established.
In determining the proofs of Live Birth, it is important to remember that
it is now an accepted fact that breathing, and much less crying, is not
necessary to establish this point, inasmuch as a child may be born, and live
1878.]
Forensic Medicine and Toxicology.
189
for many hours without breathing, so far at least as any evidence of this
process can be afforded by the lungs ; but it may, however, exhibit other
proofs of life, such as movements of its limbs and pulsation of its arteries.
This subject of live-birth sometimes assumes a medico-legal interest, as,
for example, for the purpose of establishing the tenancy by courtesy, where
the estate of a deceased wife passes to the husband during his lifetime,
provided there has been live issue. Here it becomes all-important to
prove that the child had been born living, no matter how short was the
duration of its life. To establish tenancy by courtesy, the Scotch law re-
quires that the child shall have been heard to cry. This is not the case
with the laws of England, or the United States. It should not be forgot-
ten that when the law speaks of the child being " born," it means that it
must be completely separated from the mother. Consequently, under the
law, it would not, technically, be infanticide to destroy an infant that was
even crying vigorously, provided it was not completely extruded from the
mother, but only its feet were retained ! As the authors justly remark, this
is a direct encouragement to child murder.
In examining cases of suspected Infanticide we should not lose sight
of the fact that many children are born dead, and that many others perish
at or soon after birth from various causes quite independently of violence.
This will, of course, suggest the necessity of making a careful post-mortem
examination in every such case that may fall under our notice.
We pass by the subjects of Paternity and Superfcetation as offering
nothing specially worthy of notice here, and come to Chapter XXYIL,
which treats of Unsoundness of Mind. This chapter opens with a very
just reflection on medical witnesses " making so poor a figure in the witness
box in cases of insanity." Several reasons are assigned for this, among
which is one which we quite agree with the authors in hoping may " soon
be a relic of the past," namely, "a deficient preliminary education in many
members of our profession."
We shall not attempt to give anything like a systematic analysis of this
chapter, but will content ourselves with a brief notice of a few of the more
prominent points of a medico-legal character. These may be included
under the two general heads of (1) Civil Responsibility, or the capacity
for attending to one's own affairs or business : and (2), Criminal Respon-
sibility, or responsibility for the commission of crime. Under the former
of these divisions is included the capacity to make a will, to contract a
marriage, to convey property, or execute any other contract. Under the
second, should be considered the plea of insanity, which of late years has
been so frequently urged as a bar to punishment in trials of the most flagi-
tious criminals, that it should be admitted only with the most scrupulous
caution by judges and juries.
As regards the capacity for making a will, the law allows considerable
latitude to the testator, so far as his mental condition is concerned. Even
if he be a lunatic, provided he has " lucid intervals," he may, in one of
those intervals, execute a lawful will. Cases have been decided in the
courts which go to show that a state of mind for which a party might be
placed under interdiction, or deprived of the management of his affairs,
would not render him incompetent to make a will. The test of capacity
here is, Does the person know the nature of the act which he is perform-
ing, and is he fully aware of its consequences ? If the act then is rational,
and in accordance with what might reasonably have been expected from
him, it would certainly be allowed. Even the commission of suicide
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which is often hastily assumed to be the evidence of insanity, is not to be
considered as proof of this state, although a testator had destroyed him-
self a few days after he had executed a will and the will has been held to
be valid. We should also be careful to draw the distinction between
eccentricity and delusion in pronouncing upon the validity of a will. The
will of an eccentric man, as has been rightly observed, is such as might
always have been expected from him : it is perfectly consistent with his known
character ; but the will of one laboring under a delusion is different from
that Avhich he would have made in his natural condition of mind. Cer-
tain it is that the courts have affirmed the validity of some very eccentric
wills, as in the case of Morgan v. Boys (as quoted by Dr. Taylor), where
the testator, after bequeathing the bulk of his property to his house-keeper,
had directed that his executors " should cause some parts of his bowels
to be converted into fiddle-strings, that others should be sublimed into
smelling-salts, and that the remainder of his body should be vitrified into
lenses for optical purposes." Here, certainly, was eccentricity enough ;
but the testator exhibits his consistency of character, when he subse-
quently adds in a letter: "The world may think this is done in a spirit
of singularity or whim, but I have a mortal aversion to funeral pomp, and
I wish my body to be converted into purposes useful to mankind." This
will was pronounced valid, although the heirs-at-law endeavoured to set it
aside. In concluding this subject, we would ask with all candor and
humility, " Who shall presume to define the precise limits of mental capacity,
or who will venture to draw the line exactly which separates mere eccen-
tricity from positive derangement ?"
The different varieties of Insanity, together with its causes, are treated
of in the usual manner, and at sufficient length ; these require from us no
special notice. Some very good hints are given as to the proper method of
examining suspected lunatics, and also as to the rules to be followed for
detecting cases of feigned insanity. A number of cases taken from differ-
ent authorities, and illustrating the various conditions described by the
authors, are appended ; and these are followed by some general rules for
detecting feigned bodily diseases.
Under the head of Various kinds of Death from Apncea {asphyxia), we
find included drowning, hanging, strangulation, suffocation, and death
from the inhalation of poisonous gases, and from anaesthetics. There are
so many points of resemblance in these various modes of death that there
would seem to be a propriety in thus grouping them together. We must
not, however, forget that there are certain peculiarities pertaining to each,
which deserve the consideration of the legal physician. In hanging it
should not be forgotten that neither the presence of the cord about the
neck, nor even the mark of the cord, is absolute proof that this was the
actual cause of death ; since it has been shown that if a body be sus-
pended soon after death, the mark of the cord will be visible. In ordinary
cases of hanging, whether by suicide or judicially, contrary to the popular
belief, the neck is seldom broken. To insure the fracture of the cervical
vertebrae, or of the odontoid process, it is requisite that the knot should be
placed under the chin, and that the fall of the body should be much greater
tli an it ordinarily is, or that a violent rotatory motion should be given to
it, as it is swung off the drop. Usually death by hanging is caused chiefly
by asphyxia, but partly also by apoplexy. It is important also to remem-
ber, as a medico-legal fact, that death by hanging may occur while the
feet or knees are resting on the ground — a very slight degree of pressure
1878.]
Forensic Medicine and Toxicology.
191
upon the windpipe soon producing unconsciousness in the victim, and ren-
dering him perfectly helpless. Whilst death by hanging (except judicial)
is usually presumptive of suicide, death by strangulation, which resembles
the former in many respects, is nearly always to be ascribed to homicide.
Chapter XXIX. treats of Death%produced by Lightning, Cold, Heat,
Starvation, and Burns. There is nothing under these heads requiring any
special notice on our part, the text being sufficiently full on all these dif-
ferent subjects. Under the head of burns, an important medico-legal point
to establish is, Are blisters, or vesications, on a dead body positive proof
that death was caused by fire? As the result of numerous experiments,
it has been determined that although vesications may be produced on a
dead body by the application of heat, this can only be effected Very soon
after death, and chiefly in dropsical subjects ; and, moreover, these post-
mortem vesications differ from the others in containing either gas or air,
or else a thin serum very poor in albumen.
Under the same head the subject of the Spontaneous Combustion of
Human Beings is briefly discussed. The many extraordinary accounts that
have been given of this alleged phenomenon, partake so strongly of the
marvellous and romantic, and the alleged facts themselves are so entirely
opposed to the known and established laws of science, that it is impossible
to give our assent to them. An examination of all the recorded cases,
moreover, will show there was in every instance a lighted candle, a pipe,
or some other means by which the combustion may have been commenced.
The last chapter of the book treats of Wounds and their sequences, in
relation to legal medicine. Inasmuch as very many cases of violent death
are the result of wounds, it is, of course, of the utmost importance that
the forensic physician should be thoroughly acquainted with this division
of his subject; and to do this lie must enter somewhat extensively into
the domain of surgery. The remarks of the authors are generally sound
and judicious ; they do not require any special. notice by us. A very good
table is given, showing the difference in the appearances of wounds in the
living and the dead — an important point to the examining physician in
the case of bodies found dead.
In the section on Gunshot wounds, the authors enter somewhat into
detail in their description of fire-arms, ancient and modern, together with
the flights of bullets and shells ; and they invoke the aid of the higher
mathematics in a somewhat elaborate exposition of the law of projectiles,
all of which, though very interesting to students in gunnery, will scarcely
prove as attractive to the forensic physician.
The remarks on Wounds of Special Regions are judicious and practical,
and sufficiently comprehensive. The importance of distinguishing between
compression of the brain and intoxication is very properly insisted on, and
the means of diagnosis accurately described.
We have thus endeavoured to take a survey, although a somewhat hasty
one, of the different subjects treated of in this very copious work. From
our remarks it will be gathered that we think highly of the book. It has
been, we believe, carefully and conscientiously prepared ; and although
there is nothing very original in its pages — the same information being-
obtainable from other standard authors — it, nevertheless, presents the sub-
ject of forensic medicine to the reader in a very attractive form ; and it
cannot fail to be useful to the student and practitioner of this department
of science. The book is well illustrated by means of several excellent
chromo-lithographs and numerous wood-cuts. J. J. R.
192
Reviews.
Art. XXIII Fat and Blood; and Hoiv to Male Them, By S. Weir
Mitchell, M.D., Member of the National Academy of Sciences, etc
12mo. pp. 101. Philadelphia: J. B. Lippincott & Co., 1877.
This is a book to give impulse to medical thought, and to make a per-
manent impression on medical practice. It has a mission. It appeals to
common sense, and although many of the facts and statements are based
on abstruse physiological knowledge, everything seems so familiar that we
wonder these things never occurred to, us before. The book suggests
more than it teaches. Your machine-doctor, reading it, has his eyes
opened; but he is troubled as well as amazed. He finds in it nothing
about "altering the secretions;" nothing about "rousing the liver to
action," and similar old-time phrases. In our immediate past, fat could
not be made, nor blood either, without some treatment addressed to the
secretions. The medical iconoclasts of our time seem bent on destroying
the relics of the past, and with the relics, the happiness of the old family
doctor.
Although we have numerous books devoted to food and diet, and to the
physiology of digestion, but little has been done to adapt physiological
principles to the practical needs of digestion therapeutics. Alteratives,
restoratives, tonics, etc., occupy a large space in our systematic treatises;
yet the greatest of all restoratives, and, indeed, the only one which exerts a
permanent influence — food — is practically ignored by therapeutical writers.
If the instructors of our medical practitioners neglect so important a subject
as alimentation in diseases, it need occasion no surprise that so many
routine practitioners pay but little attention to dietetic regulations. They
may be fruitful enough in the resources of the materia medica, but are barren
as respects those modifications of diet appropriate to particular indications.
The only medicines prescribed by Dr. Mitchell in Fat and Blood are iron,
and the extract of aloes to relieve the constipation caused by an exclusively
milk diet, and strychnia as a nerve stimulant.
Fat and Blood is especially concerned with certain nervous maladies.
They are so admirably depicted by our author, that we quote his description
of them : —
k ' It includes that large group of women, especially, said to have nervous ex-
haustion, or who are described as having spinal irritation, if that be the prominent
symptom. To it 1 must add cases in which, beside the wasting and anaemia,
emotional manifestations predominate, and which are then called hysterical,
whether or not they exhibit ovarian or uterine disorders.
" Nothing is more common in practice than to see a young woman who falls
below the health-standard, loses colour and plumpness, is tired all the time, by
and by has a tender spine, and soon or late enacts the whole varied drama of
hysteria. As one or other set of symptoms is prominent, she gets the appropriate
label, and sometimes she continues to exhibit only the single phase of nervous
exhaustion, or of sjmial irritation. Far more often she runs the gauntlet of nerve-
doctors, gynaecologists, plaster-jackets, braces, water-treatment, and all the fan-
tastic variety of other cures
' ' I see every week — almost every day — women, who when asked what is the
matter, reply, 'Oh, I have nervous exhaustion.' When further questioned, they
answer that everything tires them. Now, it is vain to speak of all of these cases
as hysterical, or, as Paget has done, as mimetic
"But no matter how it comes about, the woman grows pale and thin, eats little,
or if she eats does not profit by it. Everything wearies her — to sew, to write, to
read, to walk — and, by and by, the sofa or the bed is her only comfort. Ever}-
1878.]
Mitchell, Fat and Blood.
193
effort is paid for dearly, and she describes herself as aching and sore, as sleeping-
ill, and as needing constant stimulus and endless tonics. Then comes the mis-
chievous role of bromides, opium, chloral, and brandy. If the case did not begin
with uterine troubles, they soon appear, and are usually treated in vain, if the
general means employed to build up -the bodily health fail, as in many of these
cases they do fail. The same remark applies to the dyspepsias and constipation,
which further annoy the patient and embarrass the treatment. If such a person
is emotional, she does not fail to become more so, and even the firmest women
lose self-control at last under incessant feebleness If no rescue comes,
the fate of women thus disordered, is at last the bed. They acquire tender spines,
and furnish the most lamentable examples of all the strange phenomena of hys-
teria. ' '
Who has not seen many cases thus masterly described? Who does not
know now many examples of these invalids, bed-fast for years and slowly
dying, in the community immediately about them? The importance of a
right understanding of the nature of these cases, and of the means of cure,
can hardly be overestimated. They are usually regarded as hysterical, and
the resources of an ordinary general practitioner powerless even to alleviate.
Dr. Mitchell, actuated, doubtless, by the highest motives, lays his methods
before his readers with perfect frankness, and he enters into minute details
with a carefulness which shows that he desires all to profit by his excep-
tional skill. His method consists in "a combination of entire rest and of
excessive feeding, made possible by passive exercise obtained through the
steady use of massage and electricity." Before he enters upon the consider-
ation of these means of treatment, our author discusses the subject of "fat
in its clinical relations." Heredity, and the means and opportunities of
life, have an undoubted influence ; climate, still more, in the production and
deposition of fat. The remarkable disproportion in the obesity of American
and English men and women, especially the latter, has been frequently
commented on by writers, and is invariably noted by travellers. Hawthorne
in Our Old Home makes frequent mention of the fatness of English women,
and his remarks are not always characterized by that refinement and deli-
cacy of sentiment, which we expect from the author of the Scarlet Letter.
The freedom of his criticisms and its sometimes coarseness, and his patri-
otic advocacy of the superior charms of the thinner American women,
caused extreme indignation among the more cultivated classes of our Eng-
lish cousins. The following extract from his paper on Leamington Spa
will, we think, justify the observation above made on the unexpected in-
delicacy of Hawthorne's comments on the stoutness of English women : —
' ' I have heard a good deal of the tenacity with which English ladies retain
their personal beauty to a late period of life ; but (not to suggest that an Ameri-
can eye needs use and cultivation before it can quite appreciate the charm of
English beauty at any age) it strikes me that an English lady of fifty is apt to
become a creature less refined and delicate, so far as her physique goes, than any-
thing that we western people class under the name of woman. She has an awful
ponderosity of frame, not pulpy, like the loose development of our few fat women,
but massive with solid beef and streaky tallow ; so that (though struggling man-
fully against the idea) you inevitably think of her as made up of steaks and sir-
loins. When she walks, her advance is elephantine. When she sits down, it is
on a great round space of her Maker's footstool, where she looks as if nothing-
could ever move her. She imposes awe and respect by the muchness of her per-
sonality ; to such a degree that you probably credit her with far greater moral and
intellectual force than she can fairly claim. Her visage is usually grim and stern,
seldom positively forbidding, yet calmly terrible, not merely by its breadth and
weight of feature, but because it seems to express so much well-founded self-reli-
ance, such acquaintance with the world, its toils, troubles, and dangers, and such
No. CXLIX Jan. 1878. 13
194
Reviews.
[Jan.
sturdy capacity for trampling down a foe. Without anything positively salient,
or actively offensive, or indeed unjustly formidable to her neighbours, she has
the effect of a seventy-four gun ship in time of peace ; for while you assure your-
self that there is no real danger, you cannot help thinking how tremendous would
be her onset, if pugnaciously inclined, and how futile the effort to inflict any
counter-injury
' ' You can meet this figure in the street, and live, and even smile at the recol-
lection. But conceive of her in a ball-room, with the bare brawny arm which she
invariably displays there, and all the other corresponding developments, such as
is beautiful in the maiden blossom, but a spectacle to howl at in such an over-
blown cabbage-rose as this."
The tendency to the deposition of fat, which is so marked a character-
istic of our English cousins, has been ascribed to their habits of life, and to
the climate of England. The better classes, able to provide according to
their inclination, habitually consume a large quantity of animal food, and
they are not less given to the use of malt liquors and wines. The insular
climate of England is not disturbed by the rapid and extreme variations
of temperature, characteristic of the climate of the United States. The
moisture not less than the uniformity of the English climate favours the
acquisition of fat, by lessening tissue waste. Given the same social sur-
roundings, the same hearty appetite, the same generous supply of animal
food and liquors, the same result in fat forming could hardly occur to the
American, because the dry atmosphere, and possibly the extreme varia-
tions of temperature, too much increase the rate of tissue metamorphosis.
Hawthorne makes the observation that he had seen no facts which demon-
stated that the obese English woman could execute more tasks, or endure
more, than our thinner American woman.
It is probable that the supposed unfavourable influence of the climate of
North America on the first settlers and their immediate descendants, does
not continue, for a change in the opposite direction seems to be, slowly,
taking place. The men and women of thirty-five belonging to the well-to-
do-classes, and of the present generation, exhibit a marked tendency to
obesity. For example, an accurate observer, visiting at Saratoga, during
the season, must be impressed by the large proportion of men and women,
especially the latter, who are on the verge of embonpoint. These exam-
ples do not alone come from the Atlantic coast, but also from the dumb
uniformity of our western prairies.
But we must return from this digression to the subject more immediately
before us — to fat and blood. Our author entertains lofty notions of the
office of fat in the body of man. In referring to the condition of a patient,
and whenever he mentions blood and fat in the same sentence, he always
mentions fat first, and blood second. The book is an apotheosis of fat. We
believe that he unconsciously exaggerates the importance of "fat in its
clinical relations."
It cannot be denied that fat occupies an influential position. A little
fat is necessary to the stomach digestion, although it does not itself under-
go solution and absorption in that organ. If the fat taken with the food
fail of digestion, in consequence of disease of the organs concerned, rapid
emaciation ensues. It is fat that forms " the molecular basis of the chyle."
Fat is essential to the hepatic functions, and it enters largely into the com-
position of nervous matter. Besides its office in giving roundness and
symmetry to the human form, which is an sesthetical question, fat is indis-
pensable to the healthy activity of the locomotive organs, to prevent fric-
tion and to ease their motions. Whilst we freely admit the truth of the
1878.]
Mitchell, Fat and Blood.
195
physiological exposition of fat put forth by our author, we must differ from
him as respects the supreme importance of this material. In the remark-
able results obtained by Mitchell, we cannot fail to see that it is not alone
fat which accomplishes the object. The gain in weight is far from being
due entirely to fat. Under the improved conditions to which he subjects
the patients, all the anatomical elements increase in dimensions — a physio-
logical hypertrophy. That our author has a similar opinion, is intimated
in the following paragraph : —
" Looking back over the whole subject, it will be well for the physician to re-
member that increase of fat, to be a wholesome condition, should be accompanied
by gain in quantity and quality of blood, and that while increase of flesh after
illness is desirable, and a good test of successful recovery, it should always go
along with improvement in colour." (p. 21.)
We would go further than this, and say, that if the increase in the
volume of all the organs and in the locomotive apparatus, was manifested
in strength and endurance of muscles, in the vigor of the cardiac move-
ments, in an elevated tonus of the arterial system, and in an equable state
of the nervous matter, we should regard any considerable deposition of fat
as undesirable.
Under the admirable method of our author, an increased tissue meta-
morphosis ensues ; the appetite improves with the demand for material ;
the blood is enriched in all of its constituents, and the thirsty tissues are
flooded with a more generous pabulum. We would say, Blood and Tis-
sues— how to make them.
In Chapter III., little more than a page, our author indicates with re-
markable felicity the need of isolation and seclusion in certain cases.
"It is rare to find any of the class of patients I have described so free from the
influence of their habitual surroundings as to make it easy to treat them in their
own homes. It is needful to disentangle them from the meshes of old habits, and
to remove them from the contact with those who have been the willing slaves of
their caprices. ... I am now speaking chiefly of the large and troublesome
class of thin-blooded emotional women, for whom a state of weak health has be-
come a long and almost, I might say, a cherished habit. For them there is often
no success possible until we have broken up the whole daily drama of the sick-
room, with its little selfishnesses, and its era vino- for svmpathy and indulgence."
(p. 35.)
The question of " Rest," which our author takes up in Chapter IV., is
an exceedingly difficult subject. Most practitioners of the present time,
who pursue physiological rather than empirical methods, decide the ques-
tion of rest according to the habits of life, the nature of the malady, and
the need of additional oxygen to complete the conversion of chylous fluid
into blood. In a few vigorous sentences, Mitchell tells us the kind of
patients to be made to take up their bed and walk : the lazy valetudina-
rian ; the hysterical incompetent. The class of cases requiring rest have
already been distinctly defined by Dr. Mitchell. The amount and kind of
rest are indicated in the following paragraph : —
" In carrying out my general plan of treatment, it is my habit to ask the pa-
tient to remain in bed from six weeks to two months. At first, and in some cases
for four or five weeks, I do not permit the patient to sit up, or to sew, or to write
or read. The only action allowed is that needed to clean the teeth. In some
instances, I have not permitted the patient to turn over without aid, and this I
have done, because sometimes I think no motion desirable, and because sometimes
the moral influence of absolute repose is of use."
196
Reviews.
No one can possibly fail to appreciate that in many diseases enforced
rest is indispensable. Is it certain that in tlio.se patients who become
fatigued with the slightest possible effort, there is a condition of defective
nutrition ? May not this state be due to a long-established in-door life ?
Patients, women especially, disinclined to exercise, become fond of the
uneventful routine of the house, and their inclinations are ultimately sec-
onded by an increasing incapacity for all sorts of physical exercise. If
they add to the physical weakness thus engendered a considerable depo-
sition of fat, it is not surprising that the slightest effort is followed by over-
powering fatigue. Although the method of Mitchell is entirely successful
with such cases, yet it appears to the writer that a system of graduated
exercises, beginning with the least effort that does not produce fatigue and
continued patiently by slight daily additions of work, will ultimately suc-
ceed in a great majority of cases. The writer bases his opinion on various
cases conducted to a successful issue by such a method of graduated physi-
cal exercises. In the instances of so-called " hysterical joints," long dis-
use has rendered the joints exquisitely sensitive. A few days of friction
and passive motion ought to precede the efforts to exercise.
One of the most important methods of cure practised by Mitchell is
Massage. Our author was induced to undertake, systematically, this
method of cure because he had observed that very striking results were
obtained by "rubbers," " Swedish movements," etc. He has, of course,
greatly improved the methods followed by empirics, and he thinks he has
" some facts to relate in regard to it, which are not known on either side
of the Atlantic." There can be no doubt of the substantial accuracy of
this statement. Previously to Dr. Mitchell's investigation massage av;ls
used by a few specialists in neuro-pathology, but besides these, it is safe to
say, that massage was only used by " rubbers," and the practitioners of
the Swedish movements.
Notwithstanding so little was known of massage in this country, this
subject had received adequate treatment abroad. Thus we find that Trous-
seau and Pidoux have included this subject in the materia medica, and
have given a full discussion of its mode of action and therapeutical effects.
— (Traiie de Therapeutique et de Matiere Meiicale. Huitieme Edition.
Par Constantin Paul. Tome Second. Paris, 1869.)
In their historical summary, these authors show that massage is an old
expedient, that Hippocrates, Praxagoras, Ccelius Aurelianus, and others
distinctly refer to it, and that several elaborate French memoirs have been
devoted to it. There can be no doubt, however, that this subject has been
brought to the highest efficiency by Mitchell, and that for the first time
by his efforts it has been placed upon a truly scientific basis. He thus
describes the method as used by him : —
" After a few days of milk diet with which my treatment ordinarily begins, the
masseur or masseuse is set to work. An hour is chosen midway between two
meals, the patient lying in bed, the manipulator starts at the feet, and gently but
firmly pinches up the skin, rolling it lightly between his fingers and going carefully
oyer the whole foot, then the toes are bent and moved about in every direction,
and next with the thumbs and fingers the little muscles of the foot are kneaded
and pinched more largely, and the interosseous groups worked at with the finger-
tips between the bones. At last the whole tissues of the foot are seized with both
hands and somewhat firmly rolled about. Xext the ankle? are dealt with in like
fashion, all the crevices between the articulating bones being sought out and
kneaded, while the joint is put in every possible position. The leg is next treated,
first by surface-pinching, and then by deeper grasping of the areolar tissue, and
last by industrious and deeper pinching of the large muscular masses, which for
1878.]
Mitchell, Fat and Blood.
197
this purpose are put m a position of the utmost relaxation. The grasp of the
muscles is momentary, and for the large muscles of the calf and thigh both hands
act, the one contracting as the other loosens its grip. In treating the firm mus-
cles in the front of the leg, the fingers are made to roll the muscle under the cush-
ions of the finger-tips. At brief intervals the manipulator seizes the limb in both
hands, and lightly runs the grasp upward, so as to favour the flow of venous blood-
currents, and then returns to the kneading of the muscles."
Although it cannot be denied that massage has great antiquity, and is
now freely used on the Continent, still to Dr. Mitchell is due the credit of
having brought it forward in this country, of having increased the range
of its influence, and of demonstrating its physiological actions. Although
it has been noted by Trousseau that the increased warmth of the skin pro-
duced by massage is due to the more active cutaneous circulation, it was
reserved to Dr. Mitchell to put this point on an exact scientific basis by a
series of accurate thermometric observations. Influenced by his example
and stimulated by his success, we venture the prediction that massage is
destined to become the fashion, and to be applied in the treatment of all
sorts of ailments, quite irrespective of the fitness of things.
The third expedient of our author's therapeutical trinity is Faradism.
The electrodes are so applied as to cause muscular contractions : one being
placed on the belly of the muscle ; the other over the motor nerve passing
to the muscle. As the object to be accomplished is muscular contraction,
and consequently muscular exercise, only that strength of current neces-
sary to move the muscles need be employed. Dr. Mitchell's experience
confirms the results obtained by Beard and Rockwell in their method of
general electrization.
The muscular exercise produced in this way is equally as effective in
respect to the condition of the muscle as if the contractions were due to a
volitional impulse. It has been shown lately that the principal part of the
body-heat is consequent on the interchanges of waste and repair in the
muscular tissue. Complete immobility of the muscles lessens the tempera-
ture in certain animals — notably in rabbits. A muscle made to contract
under a bell-jar gives off a great quantity of carbonic acid. These physio-
logical data are entirely confirmatory of the observations made by Mitchell.
Our author has ascertained the entire correctness of a statement put
forth by Beard and Rockwell, that an induction current of fifteen to thirty
minutes' duration passed through the body by means of one pole on the
neck and on either foot, has decided tonic property if persistently used for
some time. Mitchell has, also, ascertained the remarkable fact that this
application causes in " many people" a decided rise of temperature. He
describes as follows this particular application : —
" At the close of the muscle electrization, one pole is placed on the nape of
the neck, and one on a foot, for fifteen minutes. Then the pole is shifted to
the other foot, and left for a length of time. The primary current [of a Faradic
instrument] is used as being less painful, and the interruptions are made as rapid
as possible, while the central wires or cylinder are adjusted so as to give a current
which is not uncomfortable." (p. 70.)
In the seventh and last chapter, Dr. Mitchell discusses dietetics and
therapeutics. Why dietetics? Is not food, applied with special reference
to the needs of particular cases, a therapeutical agent? In this chapter
our author enlarges on the " milk-cure," a method which he has not simply
popularized, but illustrated, by its successful adaptation to the treatment
of difficult cases. The milk-cure is as ancient as Hippocrates. Within a
198
Reviews.
[Jan.
few years it has been revived by the Montpelier school. We owe to
Pecholier, Carel, Mitchell, and others, the present exact knowledge in
regard to its effects and uses. The milk diet, of skimmed milk exclusively,
is employed to accomplish the following ends: —
To depurate by a gradual denutrition process; and to reconstruct, by a
slow molecular disintegration and renewal of the anatomical elements ; to
relieve the chylopoietic viscera of existing derangements; to give the suf-
fering organs rest, and in this way put them in a condition to do more
satisfactory work thereafter. Mitchell usually commences the treatment
of his cases by the milk-cure, and he subsequently enlarges the dietary by
the very gradual addition of suitable articles. The accumulation of fatty
tissue occurs pari passu with an improved condition of the blood. The
organs and tissues supplied by blood of richer quality improve in their
nutrition, expand to their proper dimensions, and functionate more per*,
perfectly. The increased well-being of all parts of the body thus ade-
quately supplied with material, is not more conspicuously exhibited in the
increased amount of fat than in the growth of muscular and gland tissues.
The means of treatment pursued, and the results achieved, are quite
independent of drugs. Most of the cases had been subjected to the treat-
ment by drugs, and especially by iron, before coming within the benefi-
cent influence of the new regime. But Dr. Mitchell does use a few drugs ;
he gives iron, and in enormous does, and he occasionally prescribes strych-
nia when convalescence is fairly established. The ferruginous prej arations
which he prefers are the old subcarbonate, and the newly-introduced
dialysed iron. But iron is, properly speaking, a food, and a very impor-
tant one.
Our author closes his book with the statement that the assistants who
have conducted the various details of the treatment "have come, at least,
to be amply satisfied by repeated experience of the exceptional value of
the treatment, which I now leave to the judgment of the larger jury of my
medical brothers." There can be no doubt on which side the judgment
will fall. No one can read the little volume without being charmed with
the admirable manner of its style, with the unaffected candor and integ-
rity of its author, and with the high importance of the communication
which he addresses to the medical profession.
Our author omits for obvious reasons an important element in the great
successes which this method is constantly achieving. We will not use the
pert phrase so much employed in these clays — personal magnetism. Hope,
expectancy, firm faith that the result must follow the means, are powerful
adjuvants to massage and electricity. To the nervous invalid in the dis-
tant and obscure country village, the intelligence gradually diffuses, that a
great master in the art of cure is to be seen. How the hope long deferred
revives again when such a patient is afforded the opportunity to have his
advice and treatment. The means used are so new in the experience of
the patient, so striking in their results, the confidence of the physician
and attendants so assured, that expectation rises to the highest point.
Hardly more trust is felt by the sad pilgrim to our Lady of Lourdes ;
not more miraculous appear the cures wrought by Prince Hohenlohe.
Although the method of cure so clearly taught must succeed anywhere if
rightly employed, yet an important adjuvant is fortunately found in the
confidence with which the patients may be inspired, in the willing obe-
dience to the details of the treatment, and still more, in the mastery
born of those qualities which make up the character of the really great
physician. R. B.
1878.]
199
ANALYTICAL AND BIBLIOGRAPHICAL NOTICES.
Art. XXIV. — Saint Thomas's Hospital Reports. New Series. Edited by
Dr. Bristowe, Dr. John Harley, and Mr. Wagstaffe. Vol. VII. 8vo.
pp. xiv., 392. London: J. & A. Churchill, 1876.
Some of the papers in this volume are purely surgical in character, while the
remainder will be found to be of more general interest. In accordance with our
custom, we shall notice these two classes separately, calling attention first to the
latter class.
The first of this class is a paper On the Etiology of Hydramnios, by Dr. Henry
Geryis, the Obstetric Physician to the hospital, who rightly holds that we shall
never succeed in understanding the cause of the occasional excess of the liquor
amnii until we have ascertained its source. The liquor amnii, he says, must be
derived from the mother, from the foetus, or from both. That it is not wholly of
embryonic origin is, he thinks, sufficiently shown by the fact pointed out by
Schroeder, that in cases where the embryo has become atrophied, or has even
entirely disappeared, the liquor has, nevertheless, been present, and in amount
corresponding to the age of the ovum without reference to the embryo. Essen-
tially, it is a limpid serous fluid, of slightly alkaline reaction, containing a trace of
albumen and some saline constituents, and only with the progress of gestation does
it contain urea, cast-off epidermic scales, and meconium. The author, therefore,
holds that it cannot be derived originally from the foetus. If it be not of foetal
origin, it must, of necessity, be derived from the mother, and among the maternal
structures which can produce it, it is unnecessary, he says, to look further than the
amnion. This is a serous membrane, and has every requisite for the secretion of
a serous fluid ; its lining epithelial cells being the immediate agents in the process.
Admitting that the liquor amnii is derived from the amnion, the cases in which
it is found in excess may be brought under one of three heads. 1. The excess
may be due to an inflammatory condition of the amnion. That this occasionally
takes place is attested by observations of McClintock, Schroeder, Cazeaux, and
others. 2. It may be due to disease and hypertrophy of the decidua, the amnion
itself being healthy. In cases in which this occurs, either as a result of inflam-
mation or as a sequence of constitutional syphilis, the circulation will be inter-
fered with, and as a consequence an effusion of serum will take place. 3. It
may be the result of some maternal blood dyscrasia, as for instance, that which
is present in albuminuria.
Under the name of Kakke, Dr. W. Anderson, Professor of Medical Sciences
in the Naval College, Yeddo, describes a disease which is very prevalent in Japan,
and which very closely resembles the terrible affection known in India, Ceylon,
and the south of Brazil as Beriberi. It may, he says, be defined as follows : —
"A recurrent non-febrile, non-contagious disease, endemic in certain low-lying
towns of Japan, and especially associated with over-crowding, bad drainage, and
bad ventilation ; most prevalent during the period of high temperature and heavy
rainfall, capable of remaining latent for very long periods, and of manifesting
itself, under ordinary exciting causes, in places remote from its source. The
symptoms are characterized by temporary numbness of certain portions of the
200
Bibliographical Notices.
[Jan.
surface ; paralytic affections of various muscles, most commonly those of the ex-
tremities ; the loss of power, sometimes associated with spasm, muscular hyper-
esthesia, and progressive atrophy ; dropsical effusions, usually slight, and limited
to the subcutaneous connective tissue of the lower extremities, sometimes exten-
sive, and sometimes involving serous cavities, especially the pericardium ; reflex
vomiting in the most acute cases ; abnormal excitability of cardiac motor centres,
leading, in ordinary cases, to palpitation, in acute cases, to extremely rapid action
of the heart, and consequent exhaustion of the organ, failure of circulation, and
death."
Kakke, like beriberi, not only attacks a large proportion of the population in
places where it prevails, but it is also a very fatal affection. Thus in the military
stations in the south of Japan, the whole number reported sick from this cause
forms no less than 33 per cent, of the total force of 15,000, while the mortality
from it, even under the most favourable circumstances, is about 22 per cent, and
in some localities has reached 30 per cent, of the cases. Although Kakke often
runs an extremely rapid course, death is not so apt to occur suddenly from it as is
said by Dr. Aitken to be the case in beriberi. The latter is also said by this
author to occur in the damp cold season in India, while Dr. Anderson asserts
that the former is most frequent in the rainy, warm, season of Japan.
In the few post-mortem examinations which have been made, no abnormalities
beyond dropsical effusions have been detected, but in no case, the author tells us,
have the nervous centres been fully investigated. He thinks that the cause of
the motor paralysis of the extremities, and of the spasms, must be looked for in
the anterior columns of the cord, while a localized and usually transient affection
of the posterior cornua would account for the numbness so constant at the begin-
ning of the disease. The muscular hyperesthesia is less easy to explain, as it
may originate either in the cord or in the affected muscles themselves.
The treatment of the disease appears to be very unsatisfactory. Quinia. arsenic,
carbolic acid, the sulphites, and the hypochlorites have all been tried, but only
with negative results. Strychnia has been found useful as a remedy for the
motor paralysis, but should not be given when this symptom is accompanied by
muscular hyperesthesia and severe spasm, which arc said to yield to aconite given
in somewhat large doses. The circulatory disturbance is often relieved by digi-
talis and by hypodermic injections of morphia, although the effect of the latter
passes off generally in the course of a few hours.
In the first part of his paper entitled Notes on Cases of Nervous Disorder, Mr.
W. M. Ord refers to the part played by reflex irritation in producing certain
morbid conditions of the skin. Among the cases which he reports is one of herpes
zoster, which occurred in a man fifty years of age, who had partially recovered
the use of his limbs after an attack of apoplexy. The eruption occurred upon
the paralyzed side, and while not very extensive, was accompanied by a good deal
of pain. It gave rise to ulceration which left a scar as deep as that which follows
a burn, and which was acutely hyperesthetic two years after. The author says
that in those advanced in life the pain is often much more severe than in the
young, although the eruption is frequently slight. He refers also to several other
cases in which there was good reason to believe that irritation of the genito-urinary
tract was the cause of an eczematous eruption, and alludes to the well-known fact
that chronic eczema frequently alternates with bronchial catarrh.
The latter part of Mr. Ord's paper is on some reflex influence exerted by the
skin in internal organs. In it he reports a case of capillary bronchitis and one of
enteric fever accompanied by a good deal of diarrhoea, in which the cold bath was
used with great advantage, not merely in reducing the temperature, but also in
relieving the bronchial inflammation in one case, and the intestinal complication
in the other. In a case of curvature of the spine in which paralysis of the lower
1878.]
Saint Thomas's Hospital Reports.
201
extremities had supervened, and in which the usual remedies had failed, it oc-
curred to Mr. Orel that the central nervous system might be roused from its dor-
mant state through the agency of extensive stimulation of the skin. With this end
in view, the patient was ordered to be placed in a bath at 100° Fahr. for twenty
minutes daily. The treatment proved ^eminently successful, for, after the fourth
bath he was able to move his toes, and in a fortnight, he could raise his legs from
the bed, and at the end of about six months, "was able to stand, though not to
walk without the support of a stick." A modification of the same treatment,
douches of hot water to the lumbar and dorsal region of the spine, was also
attended with very good results in a case of infantile paralysis. In fact, the im-
provement was so remarkable that we shall quote Mr. Ord's own words in speak-
ing of it. "At the end of a fortnight," he says, "the hyperesthesia had nearly
disappeared, except from the soles of the feet; the child, lying on his back, could
now kick his heels in the air. At the end of a month he began to crawl, at seven
weeks he stood, and on the 1st of September (less than three months after the
institution of the treatment), he walked into my room without any remaining
sign of over-sensibility." It should be mentioned, however, that the child was
taking, at the same time, hypophosphite of soda with cod-liver oil.
Dr. Albert J. Bernays continues in the present volume his report On the
Working of the Adulteration Act, calling attention particularly to the varying
quantity of alcohol contained in fermented liquors. Thus, he says a glass of gin
in one place contains 50 per cent, of proof spirit, in another 76 per cent. Even
beer, the national drink of the Britons, is found to vary in a most extraordinary
manner with regard to the amount of proof spirit it contains. It is not uncommon
to meet with porters, the author tells us, varying from 5.32 per cent, to 12.76.
Milk still continues to be largely adulterated with water, and it would appear to
be sufficient for the seller to admit the fact to withdraw him from under the ope-
ration of the Adulteration Act. The same is true of other articles which are
openly sold as mixtures, thus a packet of so-called cocoa, coffee, or mustard has
only to be labelled as a mixture, and there is then no further protection to the
public as to whether cocoa, coffee, or mustard be or be not the leading constituent.
It will not be necessary to notice Dr. Thomas B. Peacock's two papers on
Intracranial Aneurisms, as this subject has recently been very fully discussed in
the pages of this Journal (see number for April, 1872), by Dr. Roberts Bartholow,
of Cincinnati. In one of the three cases which are reported in this paper, the
aneurism was seated iu the right internal carotid artery immediately before it gave
off the middle cerebral artery. In the other two cases, the right and left middle
cerebral arteries were the vessels affected. Dr. Peacock has collected and tabu-
lated upwards of eighty-six cases, reported since the publication of Sir William
Gull's paper in the Guy's Hospital Reports in 1859. These he subjects to an
analysis. These papers, which form a valuable addition to our knowledge of in-
tracranial aneurisms, are illustrated by two lithographic plates.
Dr. F. Charlewood Turner in his article On the Presystolic Bruit calls at-
tention to the fact, which was, we believe, originally pointed out by Prof. Flint
in the 44th volume of this Journal, that this murmur is sometimes heard in cases
in which there is no mitral stenosis, and rejects the explanation which Prof. Gaird-
ner has proposed for it. He expresses the opinion that the murmur does not
really precede the systole of the ventricles, as is at present generally taught, and
is, therefore, not strictly a presystolic murmur. It is synchronous, he thinks, with
the beginning of this process, in this view agreeing with Dr. A. C. Barclay, whose
series of papers on this subject in the Lancet for 1872 are doubtless familiar to
many of our readers. Both Dr. Turner and Dr. Barclay believe the first sound
of the heart to be due to the tension of the auriculo- ventricular valves, but this
202
Bibliographical Notices.
[Jan.
does not take place until after the beginning of the ventricular systole. There is,
therefore, an appreciable interval between the commencement of the systole and
the time when the first sound is heard — an interval in which they hold that a slight
regurgitation through the mitral orifice may take place. Dr. Turner, indeed,
holds that there is even in health a slight tendency to regurgitation at this time,
which is, of course, very much increased in disease. But we shall let him speak
for himself.
"If there should be," he says, "a slight thickening, causing some loss of sen-
sitiveness in the mitral curtains, or perhaps if there should merely be a sluggish-
ness in the ventricular contraction, there would result an increase of this presystolic
regurgitation, and a corresponding increase of the vibratory element of the first
sound would be heard as a slight prolongation and roughening of it. Where, as
in an advanced case of mitral stenosis, the mitral curtains are obviously thickened
and stiff ; it can scarcely be imagined that their closure would be effected without
considerable reflux, sufficient to produce a well-marked ' presystolic' bruit. A delay
of the closure of the valve thus caused would, at the same time, result in a more
forcible collision of the curtains, which may account for the loudness and sharpness
of the first sound following this bruit. If the mitral curtains should become more
contracted, so as to be no longer capable of being brought into exact apposition,
the harsh, rough 'presystolic' bruit would be followed by a softer blowing murmur
of continued regurgitation."
The paper contains the reports of several cases which the author adduces as ar-
guments in favour of the position he takes, and is illustrated by some sphygmo-
graphic tracings, which he believes sustain the same view.
In the beginning of his paper On the Mutual Relations of the Birth-rate and
Death-rate, Dr. J. S. Bristowe refers to a criticism which was made by a cor-
respondent of the London Times of Dr. Richardson's assertion that in his vision-
ary city " Hygeiopolis" the annual death-rate would be reduced to five per cent.,
the correspondent maintaining with some show of argument that a mortality of
five per cent, implied an average duration of life of two hundred years. Dr.
Bristowe, however, shows that this is only true in a population which neither di-
minishes nor increases, and in which the removals by death are exactly balanced
by the additions by birth. He, therefore, insists upon the importance in estimat-
ing the death-rate of taking the birth-rate into account.
Dr. Bristowe also contributes a second paper, entitled Note in Reference to
the Welsh LL and certain other Surd or Aspirate Consonants, which is rather
difficult to analyze. We fancy, moreover, that it will possess little interest for the
majority of our readers.
The volume also contains a Continuation of the Medical History of the Clergy
Mutual Assurance Society. From it we learn that during the forty-five years
that have elapsed since the foundation of the Society, 1135 deaths have occurred
among the insured, of which 1023 were of clergymen, 55 of laymen, and 57 of
females. It would also appear that clergymen have as good a chance of long
life as any other body of men. Thus the insured clergymen came in at the average
age of 40, and died at the average age of 57.8, living for an average period of
17.8 years. The laymen seem to have entered at a somewhat earlier age, viz.,
36.6, and to have died considerably sooner, viz., at 49.9, giving an average dura-
tion for their insurance of 13.3 years. The females entering at an average of 44.8,
died at an average of 57.1, giving only a duration of 12.3 years. This corrobo-
rates the general impression that female lives have not paid so well as males.
From the Report of the Obstetrical Department we learn that during the year
1875, 1438 women were attended, 22 of the births were of twins, 7 women aborted,
and 6 children were still-born. Placenta prasvia occurred 8 times, and breech
1878.]
Saint Thomas's Hospital Reports.
203
presentation 18 times; five of the children being born dead. Two maternal
deaths are recorded. A case of pemphigus following delivery is reported.
The Medical Report, as usual, contains several tables showing the character
and number of the cases treated in the medical wards during the year.
Appended to the volume is a short sketch of the life and services of Richard
Gullett Whitfield, who held the office of apothecary to the Hospital for upwards
of forty-five years. J. H. H.
The first surgical paper we shall notice is one On Cleft Palate, by Francis
Mason, F.R.C.S. Mr. Mason first gives a cursory but interesting historical
resumS of the varieties and anatomy of these cases, together with an account of the
preliminary attempts at cure which have led up to the advanced operations under-
taken at the present time for the relief of this deformity. Throughout the intro-
ductory portion of the paper illustrative cases are cited from time to time, which
give interest to a somewhat well-worn subject.
The operations are divided, in accordance with the kind of deformity for reme-
dying which they have been devised, into staphylorraphy, where the soft palate
alone is involved, and uraniscoplasty (sic), and osteoplasty or those instances
where the deficiency exists in the hard palate. The term uraniscoplasty has
one more syllable than our old friend uranoplasty, which addition certainly does
not add to the euphony of the word. Indeed these Greek terms so commonly
attendant upon new surgical measures are, to our mind, of questionable utility,
not having the recommendation of antiquity ; for they have not come down to us
from the ancients, but are of modern coinage, and are merely clothed in the
garb and language of the past for the convenience of foreign readers. That
the foreign reader may sometimes be helped to an understanding of the sub-
ject by such sesquipedalian terms, there can be little doubt, yet the very weight
of such terms is a hindrance, and is commonly found to prevent their daily use
among English-speaking surgeons.
Mr. Mason has had some success with the use' of escharotics, and regards the
treatment of cleft palate by touching the edges of the fissure with them, while
somewhat tedious, yet as fairly satisfactory. Mr. Mason very properly urges
the importance of patients being in the best possible general health before an
operation is undertaken, and thinks that preliminary purging, by reducing the
strength, impairs the prospect of success. His preference is for chloroform, as
an anaesthetic, for the reason that ether excites the secretions, and he advises
the use of a gag, and as simple apparatus as possible. It is hardly worth while to
enter here into the oft-repeated discussion of the merits of ether and chloroform,
yet we must record a protest against this recommendation of a less safe, though
more convenient agent, over one more safe, but less convenient. Few patients,
we take it, would knowingly incur even the small percentage of risk attending
the administration of chloroform, if they were aware of the now demonstrated
fact, that the risk from the use of ether is much less. Contrary to the advice
of Sir William Fergusson, Mr. Mason's experience induces him to leave the
sutures to work their way out unless there is manifest irritation set up by their
presence. While endorsing the plan of dividing the faucial muscles to secure rest
of the stretched velum, Mr. Mason thinks that the division should be the last step
in the procedure rather than the first, as was suggested by Fergusson.
Passing on to a consideration of the operation for closure of the hard palate,
Mr. Mason recommends that in those cases in which hare-lip is added to deficiency
of the palate an operation upon the lip should be done without any delay, as by
this means the palatal fissure is often induced to contract very considerably. In
performing this operation, uraniscoplasty, Mr. Mason follows the method of
204
Bibliographical Notices.
[Jan.
Langenbeck in detaching the mucous membrane and periosteum from without
inwards, thinking that by this means a thicker and stronger flap can be obtained
than by dissecting from the median line towards the periphery.
Osteoplasty does not receive very hearty commendation from our author,
although he occasionally practises it ; for, no matter how carefully performed, his
experience leads him to look upon some subsequent exfoliation of bone as un-
avoidable.
This article, like the one contributed by Mr. Mason to the last volume of these
reports, is rather suited for the tyro in surgical science than the experienced prac-
titioner of the art, being such an epitome of its subject matter as would find its
more appropriate position in the guise of an introductory lecture to a class of
students, as it is somewhat too meagre in cases and experimental details to be
properly included in the reports of the practice from a great general hospital.
Mr. Samuel Osborn, F.R.C.S., furnishes the next surgical article, and dis-
courses On the different Forms of Hydrocele of the Tunica Vaginalis, and treats
his readers to an abstract of leading surgical opinions concerning this disease. He
lays stress upon the distinction existing between visceral and parietal hydrocele,
regarding the former as a local attendant upon disease of the testicle, or epidid-
ymis, and requiring treatment directed to the original cause, while the latter is
looked upon as a local dropsy. Mr. Osborn emphatically condemns the tapping
of a visceral hydrocele, maintaining that the affection of the testicle should first
and chiefly receive attention. The distinction is a very nice one, and without
doubt lies at the foundation of those instances, by no means rare, where an opera-
tion is not speedily and at once successful; yet we question the propriety of east-
ing doubt upon its efficacy even in these cases, as quite often the abnormal con-
dition of the testicle is first made apparent upon the withdrawal of the surrounding
fluid, and the necessity for other treatment is in this way made known ; nor are
we able to conceive of a case in which the removal of the fluid can exercise other
than a favourable influence upon the testicle itself. Mr. Osborn' s experience
leads him to agree with Gerdy and Velpeau that idiopathic hydrocele occurs
with greater frequency upon the left side, although in this conclusion he differs
from so high an authority as Mr. Curling. One valuable statistical table is fur-
nished by Mr. Osborn. Out of fifty-four cases where the injection of iodine was
resorted to in St. Thomas's Hospital, the same measure had previously failed in
nineteen. Out of twenty-five cases operated upon by this method whose after
history was obtained, a recurrence of the affection took place in no less than
eighteen, and in two of this latter number the iodine treatment had failed pre-
viously. It will thus be seen that while a pretty large proportion failed to respond
successfully to the first injection, but a small number were unimproved by a second
operation. These results coincide pretty closely with the experience of the writer
of this notice. It is quite customary to speak of and treat a hydrocele as a trivial
matter, and such it very often is, but notable exceptions occur which may cause
both patient and surgeon no little anxiety. There is often a disagreeable element
of uncertainty even in tapping a hydrocele, from the fact of the walls of the sac
being too thick to allow of the application of that diagnostic experimentum crucis
the transmission of rays of light, and there is always great uncertainty as to the
amount of inflammation we may induce by our operative measures ; for on the
one hand it may be too slight to accomplish the result we aim at, while on the
other it may very easily become excessive, and we may find ourselves with a
troublesome orchitis to treat. Mr. Osborn' s article is by no means exhaustive,
and the same criticism will lie against it as against that of Mr Mason, namely, that
it lacks entirely that element of recorded results of practice which are naturally
looked for in hospital reports.
1878.]
Saint Thomas's Hospital Reports.
205
Anatomical Variations, II., by W. W. Wagstaffe, F.R.C.S., Assistant-
Surgeon and Lecturer on Anatomy, and Robert AY. Reid, M.D., M.C.,
Demonstrator of Anatomy, relates certain anomalies observed in the dissecting
rooms of the Hospital during the winter of 1876 and 187 7. The first and most
interesting case was of "a large bony growth projecting from the middle of the
front of the humerus, and attached by ligament to the front of the coronoid pro-
cess of the ulna," which divided the brachialis anticus into two planes, and by
impaction against the soft parts of the forearm in flexion must have interfered with
the usefulness of the upper extremity during life. Muscular abnormalities
noticed were a double omo-hyoid — varieties of the stylo-hyoid, which from their
attachments might be appropriately called stylo-chondro-hyoideus, and stylo-hyo-
pharyngeus. The rare extensor pollicis et indicis was observed twice, and a
tibio-accessorius once.
Three Cases of Imperforate Rectum recorded by H. H. Cluttox, F.R.G.S.,
Resident Assistant Surgeon, form the subject of the next surgical article. The
first case was of an infant two days old, in whom, though there was a well- formed
anus, there was no connection with the gut. A slight but firm cord could be felt
leading up to a tumour situated so far forward in the pelvis that much doubt was
entertained whether it was the bladder or rectum. This doubt having been cleared
up by finding that the free flow of urine through a catheter did not affect the
bulk of the tumour, a trocar was thrust into it, and the appearance of meconium
at once demonstrated the fact that the rectum had been reached. Comjolete relief
followed the operation The after-treatment consisted in dilating the puncture,
without any attempt being made to bring down the mucous membrane. After
three weeks the orifice was found to have contracted, and dilatation with incisions
of the stricture were resorted to. Six months later it was found necessary to again
incise the parts, after which a good recovery ensued. Mr. Glutton thinks that
had the mucous membrane been brought down and attached to that on the vero-e
of the anus the after-trouble would have been averted.
In the second case, also in the person of a child two days old, no tumour could
be detected, and a careful dissection was carried on along the anterior surface of
the sacrum. Meconium appeared at a depth of two and a half inches from the
margin of the anus, but it was impossible to bring the bowel down, as it seemed
firmly attached to the sacrum, and was situated at so great a depth. The patient,
although healthy and well nourished, succumbed to convulsions three days after
the operation. Mr. Glutton refers to a case by Mr. Le Gros Clark, cited in ' ' Cur-
ling on Diseases of the Rectum," where a permanently good result ensued in a
case where, on account of the great depth of the parts, it was impossible to bring-
down the gut, and questions the propriety of the extended incisions required to
accomplish this end in such cases.
In Mr. Glutton's third case, in a child four days old, the dissection was carried
to the promontory of the sacrum, and, as no bowel was found, the next day
Littre's operation in the left inguinal region was performed. This step afforded
complete relief at first, but after some days, the child, without any symptoms of
peritonitis, began to waste, and, eighteen days after the operation, died in a
condition of great emaciation. Upon post-mortem examination, the rectum was
found one inch and a half from the anus, unattached to the sacrum, having been
missed in the first operation. That this error should have occurred is thought by
the writer of the paper to have been owing to the fact that the bowel contained no
meconium at the time of the exploration, and he thinks that had the wound been
explored again before resorting to colotomy, the rectum might have become by
that time sufficiently distended to be recognized. It was intended to have passed
a probe down from the opening in the groin, and to have cut down upon its ex-
206
Bibliographical Notices.
[Jan.
tremity from the anus, but the decline and death of the child precluded the adop-
tion of this measure. This paper, as a faithful and honest record of experience,
is of much value, and is such a one as is naturally, yet too often vainly, looked
for in a volume of hospital reports.
A brief Report of St. Thomas's Hospital Medical and Physical Society forms
the next paper. Condensed accounts of the proceedings of ten meetings in the
session of 1875-76 are given, which, while doubtless possessing interest and afford-
ing instruction to the members of the society, contain nothing which can be made
of value to the general profession by a notice at our hands. The various subjects
discussed were diet; consanguineous marriages; digestion in plants; diarrhoea;
antiseptic surgery ; treatment of inflammation ; life, and the phrenological system,
each of which is dismissed in a very few words.
Mr. William Mac Cormac contributes the next article, consisting of interest-
ing and well-told Notes of a Case of Removal of the Scapula. The case occurred
in the person of a young woman, twenty-nine years old, who, sixteen years before,
felt pain in the shoulder, but perceived no growth until within seven years. At
that time, 1869, a lump the size of a walnut was discovered, which continued to
grow painlessly to the size of a large orange at Christmas, 1875. From that time
the tumour grew rapidly, and great pain was experienced. "On admission, a
rounded tumour, quite as big as a boy's head, was found to involve the whole
scapula, except the tips of the acromion, and coracoid processes. It bulged up
into the neck beneath the trapezius, lay over the subclavian vessels, and filled the
posterior half of the axilla, having clearly invaded the subscapular fossa." The
skin was tensely stretched over the growth, adherent in some places, and changed
in colour. The tumour measured twelve inches from its upper to its lower border,
was circumscribed and freely movable upon the thorax, and from the distinct
fluctuation was evidently cystic in some parts. On May 10, 1876, Mr. Mac Cormac
removed the scapula and attached growth. The clavicle was first sawed across
close to its acromial end, through a horizontal incision made over it, from the
acromion towards the spine, and by which also free access could be obtained to
the subclavian vessels, should the hemorrhage become excessive. Vertical in-
cisions were then made, and the mass dissected from below upwards. During
this dissection, the subscapular artery was felt in the flap, and grasped by an
assistant before division, and bulldog forceps were applied to each vessel as cut.
By these precautions, but little blood was lost, and the patient made a good re-
covery under antiseptic treatment of the wound. Unhappily the disease recurred
some months later in the neighbourhood of the clavicle, and in the lungs, and the
patient speedily succumbed to its advance. The original tumour and the recurrent
growth were found to closely resemble each other, presenting the characteristic
appearances of a myxoma, with here and there some of the large nucleated cells
peculiar to cartilaginous tissue, and it is, therefore, judged by the author of the
paper to be rightly styled a myxo-chondroina. Mr. Mac Cormac draws attention
to the fact of the long and painless duration of the disease until a short time before
the operation, when he thinks the increased activity and pain were coincident to
the addition of the myxomatous element upon the original long-existing enchon-
droma. The transformation of a benign into a malignant growth is frequently,
in our experience, accompanied by the symptoms to which Mr. Mac Cormac
alludes, and it is to relieve the pain, then, for the first time, severe, that resort to
so severe an operation becomes justifiable. Particular attention is called to the
preliminary division of the clavicle as a step by which the subsequent proceedings
were very materially facilitated. The paper is a notable one among its fellows in
the volume before us, and it is a noteworthy fact that its author presents himself
without title added to his name.
1878.]
Me die o - C hirurgi cal Tran sac ti on s .
207
The Surgical Report, 1875, by Samuel Osborn, F.R.C.S., Surgical Regis-
trar, is a valuable analysis of the work clone in the surgical wards of this time-
honoured hospital, but is too condensed to admit of the compression required by
the limits of this notice. By it we learn that there are two hundred and twenty
surgical beds in St. Thomas's Hospital, of which from one hundred and eighty
to one hundred and ninety are constantly occupied by fifteen hundred and ninety
patients, whose average stay in hospital was thirty-five days, and whose mortality
was 10.4 per centum. Three tables are given. No I. presenting an abstract of
cases according to the authorized nomenclature, with an analytical summary, and
a sub-table giving the number of cases of erysipelas occurring. Table No. II.
records the cases of pyaemia, and No. III. the operations performed.
In noticing the surgical articles of this volume we have been impressed with the
fact that they constitute but a small portion of it, either in size or importance.
But a moiety of the surgical staff are among its contributors, and in the papers
contributed there is not much evidence of painstaking labour. The material fur-
nished by fifteen hundred and ninety surgical cases, has been apparently devoid
of interest, as but few of them figure upon the pages which profess to record the
surgical experience of this great and wealthy hospital. Even in those instances
where a subject has been taken and written upon, there is no manifestation of that
thorough experimental study which can alone make monographs valuable, but the
matters are treated of very much in the style of graduation theses, so that the
question is forced upon the reader, Is it worth while to continue the publication
of an annual volume which must contain so much padding, and which from the
want of interest on the part of the surgical staff, or for some other reason, is lacking
in great measure of interest to the general surgical reader ? Would it not be better
to make the volume a biennial one, than to keep up its size and frequency, with-
out reference to the scarcity of material suited for its pages? S. A.
Art. XXV. — Medico-Chirvrgical Transactions. Published by the Royal
Medical and Chirurgical Society of London. Second series. Volume xli.
8vo. pp. lxvi., 430. London : Longmans, Green, Reader & Dyer, 1876.
We shall call attention at the present time only to those papers in this volume
which have not already been laid before our readers, either in previous numbers
of this Journal, or in its adjunct, The Monthly Abstract of Medical Science.
Th'e first of these is a Note on Pathological Absorption Spectra, by Dr. Edward
Lawton Moss, in the course of which he takes occasion to say that the spectro-
scope yields the earliest evidence of the hsematuria of Bright' s disease. In a case
of that affection, recently under his observation, the Sorby blood bands in the
urine preceded any definite identification of albuminuria by the ordinary tests,
though the daily quantity of urine was already increased. In a case of cirrhosis
of the liver, the urine exhibited, in addition to the ordinary urinary absorption,
diffused more or less equally over the whole blue end of the spectrum, a well-de-
fined and intense band, lying between 1700 and 2100 of Kirchoff's scale. After
several experiments, the author found a similar band in a solution of normal acid
feces. It was, however, altogether absent in healthy alkaline feces. This band
in the spectrum of urine and feces disappeared on neutralization with ammonia,
but reappeared on reacidulation.
Mr. Henry Trentham Butlin contributes a paper giving the result of his
examinations of The Minute Anatomy of Two Breasts, the Areolce of which had
208
Bibliographical Notices.
[Jan.
been the Seat of Long-standing Eczema, which were undertaken -with the view of
determining whether or not the connection, which Sir James Paget (see number of"
this Journal for October, 1875), believes to exist between long-continued eczema
of the nipple and carcinoma, is real or only apparent. In addition to the changes
in the mucous layer of the epidermis, and in the corium, which are usually found
in eczema, the microscope showed that the galactophorous ducts were widely open
or distended. They were not lined as in the normal condition by cylindrical
epithelium, but contained frequently large masses of epithelium of the squamous
or glandular form. In the immediate vicinity of the ducts the connective tissue
was discovered frequently infiltrated with small round cells. An induration which
existed in one of the breasts, and which to the naked eye presented much the
same appearance as certain forms of cancerous infiltration, was also examined. Its
acini were found to be much larger than normal, and to be filled with epithelium.
They were also more widely separated than is the case in health. These condi-
tions resemble very closely those the author has several times found in the imme-
diate outskirts of carcinoma of the breasts, and are described by Waldeyer in
his articles on the development of carcinoma.
In conclusion, Mr. Butlin says, "There being no cancer in these breasts it is
impossible to say that cancer would have formed in either. The facts before us,
however, are not without importance, since they show that considerable changes
are capable of being induced in the very substance of a more or less deeply-seated
organ, apparently by the presence of a very slight area of disease on the surface."
From the Notes on the Bouton de Biskra, which are communicated by Dr. H.
Vandyke Carter through Dr. J. Burdon Sanderson, we learn that this disease
commences as a superficial papule or pimple, which, in the course of some days,
becomes a nodule or "bouton," and, then acquiring a scab, often ends as a very
indolent ulcer ; that the ordinary duration of the eruption is five or six months,
or from November to April ; and that the spots may be numerous, secondary ones
appearing round the first, or at a distance. Very little local pain or redness at-
tends the "bouton," and, as a rule, there is no constitutional disturbance whatever.
General treatment has not been found to influence the course of this affection ; and,
locally, caustic applications are alone of any use.
The microscope showed that the clou de Biskra is essentially a granulation tu-
mour, i. e., a tumefaction caused in chief part by the advent of pale round cells,
which becoming densely crowded in the cutis, produce expansion of the connective-
tissue meshes, eflacement of the papillae, and the disappearance of the adjoining
softer epidermis. But permeating this cellular infiltration, and especially frequent
at its outskirts, were seen numerous bulging and branching channels, which were
usually filled with filamentous or myceloid structures. On transverse section,
round spaces appeared similarly occupied, and it became evident that the lym-
phatic vessels of the parts implicated were the seat of a foreign growth, which
must be regarded as strictly parasitic in its characters. Dr. Carter thinks there
can be no reasonable doubt that this parasitic growth is the essential cause of the
' ' bouton' ' de Biskra, believing that the presence in the tissues of a foreign growth
would be a sufficient reason for all the signs of irritation which are seen in the
tumour of the skin. A further proof of the parasitic nature of the affection is to
be found in the fact that Dr. E. Weber, Medecin-Majeur, 3me. Batn. d'Afrique,
has succeeded in showing that it is inoculable.
In view of the fact that the bouton de Biskra is eaused by a lowly organized
parasitic growth, Dr. Carter proposes to call it Mycosis cutis, adding the word
chronica to indicate a distinction from the similar acute disease.
Surgeon-Major J. H. Porter reports a case of Intermittent Hemorrhage from
Malarial Influence, the subject of which was a young man whose left leg had been
1878.]
Medico-Chirurgical Transactions.
209
amputated at the knee-joint for what would appear to be strumous disease, although
the author speaks of it as rheumatism. At first the patient did well, but at the
end of a few days the favourable progress was broken by a succession of hemor-
rhages, occurring at irregular intervals, and extending over several days. Xo
treatment was of the slightest avail in preventing the loss of blood, until Surgeon
Porter remembered that his illness had begun with a severe attack of intermittent
fever, and put him on anteperiodic doses of quinia, when it was at once arrested.
Dr. William Roberts, of Manchester, is the author of a paper On the Esti-
mation of Albumen in Urine by a New Method^ Adapted for Clinical Purposes,
which consists essentially in progressively diluting the urine, and testing it from
time to time with nitric acid, until the opacity induced by the acid becoming
gradually fainter and fainter, at length ceased to be visible. This point is reached
when the diluted urine contains less than about 0.0014 per cent, of albumen. As
it is impossible to fix the vanishing point of the reaction with accuracy, Dr.
Roberts drew the line at a reaction coming into sight midway between half and
three-quarters of a minute after the addition of the acid ; that is, he diluted the
urine until it gave no reaction for thirty seconds after the contact of the acid, but
showed a distinct opalescence at the forty-fifth second. Each dilution with a
volume of water equivalent to the unit volume of urine employed was counted as
one degree on the scale; and these degrees might be conveniently termed "degrees
of albumen." Thus a urine which required forty volumes of water to reach the
zero reaction, might be described as possessing 40 degrees of albumen, etc. When
the zero reaction is determined, the degree of dilution required to produce it was
noted and expressed in multiples of the unit volume of urine employed. Thus,
if 5 c. c. of urine gave the zero reaction when diluted up to 400, i. <?., at the
eightieth dilution (4?° = 80), the urine was registered as possessing 80 degrees of
albumen. The author found, by first ascertaining the degrees of albumen by the
dilution method, and then estimating the quantity of albumen by the weighing
process, that each degree on the dilution scale corresponded to 0.0034 per cent,
of albumen. The proportion of albumen in a urine was, therefore, obtained by
multiplying the degrees of albumen by the co-efficient 0.0034. For example, a
urine which possessed 250 degrees of albumen contained 0.85 per cent, of albu-
men (250 X 0.0034 = 0.85). From these data it is easy to calculate the daily loss
of albumen by the urine. Suppose 1200 c. c. of urine to be voided in the twenty-
four hours, and that a sample of this urine showed 250 degrees of albumen, i. <?.,
0.85 percent., then 'j2^0 x 0.85 = 10.2; the daily loss of albumen would, there-
fore, be 10.2 grammes.1
The author says, in conclusion, that the dilution method compares favourably
with the weighing process, even in urines selected for their suitability to the latter
process, but it excels it in the diminished time and trouble required for its perform-
ance, and also in its more general applicability to all grades of albuminous urines.
Dr. J. TTickham Lego contributes a paper embodying the results of his ex-
aminations in ten cases as to the amounts of Urea and Chlorides in the Urine of
Jaundice, in which he shows that these bodies are not so much diminished as from
theoretical considerations we might suppose they would be. It is also noteworthv
that in the case in which the excretion of urea was the highest, the obstruction
1 In the measures more usually used in this country the calculation is made as fol-
lows : Suppose, as above, that the urine contained 0.85 per cent, of albumen, and that
the quantity voided in twenty-four hours was forty fluidounces. Each fluidounce
437 .5"
contains 437.5 grains, the X 0.85 X 40 = 148.75, the daily loss of albumen would,
therefore, be 148.75 grains.
Xo. CXLIX Jan. 1878. 14
210
Bibliographical Notices.
[Jan.
to the bile-ducts was likewise found after death to be complete, and in the second
highest case, in which, however, no examination after death was made, the jaun-
dice had been deep for several years, and the stools had been colourless through-
out that time.
The tumours which furnished the material for Dr. Wm. R. Go we its' s paper On
the Development of Spindle Cells in Nested Sarcomas were all good examples of
this particular kind of growth. The paper is illustrated by a plate showing the
development of spindle cells by what Dr. Creighton calls vacuolation. The rela-
tion of this process of cell-development to the formation of concentric nests can
also be traced in some of the drawings given in the plate. The author says that
this process of vacuolation plays a very important part in the transformation of
the tissue elements of many morbid growths.
Dr. R. Douglas Powell contributes a valuable paper On Some Effects of
Lung Elasticity in Health and. Disease. After referring to Mr. Hutchinson's
and Dr. Hyde Salter's views on the physiology of respiration, the author points
out the fact that in the normal position of thoracic repose the contractility of the
lungs is exactly counterpoised by the elastic resilience of the chest walls. In
other words, at the close of expiration, the thoracic parietes are drawn inwards
further than their own resilience would carry them by the elastic recoil of the
lungs. It is obvious, therefore, he says, that the elasticity of the chest wall is a
force, not only in favour of inspiration at the commencement, but against expira-
tion at the termination of the respiratory act. It renders easier the expansion of
the chest, by neutralizing the first resistance and inertia of the lungs, and in the
final contraction of the chest in expiration exercises a buffer-like action in taking
off the shock of recoil. This elastic help at the beginning and elastic hindrance
at the end of the respiratory act is a spring-like function of the chest wall, to
estimate the importance of which it is only necessary to glance at the emphyse-
matous chest, when the uneasiness entailed by its loss will at once be seen. The
lungs in emphysema have not lost all their elasticity, but they have lost so much
of it that the eccentric thoracic and diaphragmatic resilience has nothing to
oppose it, the chest boundaries are no longer, therefore, drawn inwards by the
lungs in expiration beyond the position they would assume of their own accord.
The author, therefore, cannot adopt the generally received opinion that the chest
is expanded in emphysema in consequence of the pressure of the lungs, believing
that it is simply due to the diminished power of these organs, on account of the
loss of their elasticity, to oppose successfully the resilience of the thoracic parietes.
Just as the elastic tension of the lung draws upon the thoracic wall, and has,
as its counterpoise, the resilience of the ribs and cartilages, so, in the median line,
the elastic lung o'n one side draws upon the mediastinum, and has, as its counter-
poise, an equal traction of the opposite lung. If, therefore, from any cause, the
elasticity of one lung be impaired, the mediastinum, and, of course, the heart with
it, will be drawn to the opposite side. Now in some cases of pneumothorax which
have come under Dr. Powell's observation, the communication with the bronchus
was free and patent, allowing the air to pass to and fro through the lung with
inspiration and expiration. Under these circumstances no intra-pleural pressure
can exist, and yet the heart was displaced. He contends, therefore, that the
primary cause of displacement of the heart in pneumothorax is not air-pressure
acting from the diseased side, but lung-pressure acting from the healthy side.
The mechanism of displacement of the heart in cases of fluid effusion into the
pleura, he believes to be essentially the same. " Cardiac dislocation occurs," he
says, "in pleurisy pari passu with the effusion ; whereas, if its occurrence were
a, matter of pressure, it should not take place so long as the fluid no more than
occupied the space left by the contracted lung." He adds, however, that in cases
1878.]
Medico-Chirurgical Transactions.
211
of considerable fluid effusion into the pleura, there is, of course, always pressure
upon the heart.
Dr. George Thin contributes a paper On Some of the Changes found in
Cancer of the Skin or Epithelioma, with special reference to the source of the
newly formed epithelial cells, which will be found to be of great interest to micro-
seopists. The preparations which are more particularly described were obtained
from a case of epithelioma of the lip of a woman, which was caused by smoking
a very short and dirty black pipe. The disease, according to the author, who
has operated in seven cases, is not rare in some who smoke, but it apparently
does not occur in others. As the paper is a very long one we will give a portion
of the general conclusion with which it ends.
" In this disease," he says, "there is an abnormal growth of epithelium and a
morbid condition of the fibrillary tissue of the cutis." In addition to this there is
a development of lymph-corpuscles into epithelium, when brought into contact
with the epithelial cells already existing, which is a process that also takes place
in health, and cannot, therefore, be considered as in itself peculiar to cancer,
although the enormous extent to which the process develops is characteristic of
the disease. This is shown, not only by the increased development which takes
place in the immediate neighbourhood of the epithelium, but by changes in lymph
cells at a considerable distance from it, which are of a more or less marked epithe-
lial character. "I have thus arrived," to quote his own words, "at results
similar to those obtained by Classen in the cancerous cornea, and as regards the
growth of epithelium from colourless blood-cells in physiological conditions, I
am in accord with the views expressed thirty years ago by Addison, and more
recently by Biesiadecki and Pagenstecher."
Dr. William R. Go wees' s paper On Athetosis and Post-Hemiplegic Dis-
orders of Movement will be found worthy of careful study, especially by the
student of nervous diseases. Under the name of "Athetosis," it will be remem-
bered (see number of this Journal for January, 1874), Dr. Hammond first de-
scribed, in his Treatise on Diseases of the Nervous System, a peculiar affection
"mainly characterized by an inability to retain the fingers and toes in any posi-
tion, in which they may be placed, by their continual movement." These move-
ments never occur in limbs the seat of an absolute paralysis, and in the cases
which came under Dr. Hammond's observation had not been preceded by it. He
hence not unnaturally inferred that they are entirely distinct from those occasion-
ally seen after hemiplegia in early life, and more rarely after hemiplegia in adult
life, giving us as a means of distinguishing them, that in the former the disordered
movements continue during sleep, while in the latter they occur only on voluntary
movement. Much weight, however, cannot be attached to tins distinction, for
Dr. Hammond has recently claimed as instances of athetosis cases in which the
movements ceased during sleep, and the author reports in this paper a case, in
every other respect typical, in which the irregular movements occurred in limbs
previously paralyzed. In this case the symptoms, which unquestionably depended
upon syphilitic disease of the brain, almost entirely disappeared under treatment
with the constant galvanic current, after the use of the iodide of potassium and
other remedies had failed to effect any improvement. Dr. Gowers further points
out that, in each of Dr. Hammond's cases, the motor disturbances had been
preceded by sudden cerebral symptoms, and in some was accompanied by hemi-
plegia numbness. "There is thus evidence," he says, "that the pathological
change causing the disordered movements was in some cases secondary to a sudden
lesion. Whether such lesion led to motor loss of power would be very much a
question of position and extent."
All the symptoms in post-hemiplegic disorder of movement point to a lesion,
212
Bibliographical Notices.
[Jan.
Dr. Gowers thinks, which damages more extensively than it destroys the brain
tissue, and hence to softening rather than to hemorrhage. It seems essential,
too, that the gray matter affected shall be in some connection, direct or indirect,
with the volitional centre, as in no instance of post-hemiplegic spasmodic move-
ments was there an absence of voluntary power. There have not been many
post-mortem examinations in these cases, but the author says that there can be
little doubt ihat the seat of the lesion is in the corpus striatum and optic thalamus,
while there is reason to believe that some regular alternating movement may be
due to disease of the gray matter in the pons Varolii. It will be seen, therefore,
that he does not agree with those writers who ascribe these disorders of movement,
following hemiplegia, to secondary spinal change.-.
Dr. Gowers reports eighteen cases of post-hemiplegic disorders of movement,
and the conclusions he draws from them are therefore valuable ; but, inasmuch
as most of his observations in regard to this condition have been anticipated by
Dr. Weir Mitchell, we shall notice only those which seem to us most important.
All the forms of disordered movement are far more frequent in the arm than in
the leg, and when they exist in both, they are more severe in the arm. The
leg is usually very slightly affected. The spasm may, when slight, be confined
to the hand; when it involves all the parts of the arm, the hand is always the
most severely affected. In the hand, the intcrossei suffer especially. They
never occur in limbs the seat of an absolute paralysis. In some of the most marked
cases the affected was as strong as the healthy limb. In certain conditions the
spasm is increased or diminished. It is always slighter and often ceases when
the limb is at rest ; being increased or produced by voluntary effort. It is in-
creased by an effort to overcome it by passive force, by cold, and by fatigue ;
and lessened by warmth, by rest, and generally during sleep. The ataxy is not
increased by closure of the eyes. The affected muscles are sometimes of normal
bulk, sometimes actually hypertrophied, sometimes wasted. The positions
assumed by the hands and feet in some of the cases reported in this paper are
well shown in an accompanying plate.
Dr. A. L. Galabix is the author of an article On the Causation of the Water
Hammer Pulse, in the course of which he shows that the quality of suddenness
which is so characteristic of the pulse of aortic regurgitation, is usually less well-
marked in the carotid and subclavian arteries than in the radial artery, and even
in some cases than in the dorsalis pedis. In other words, it is a quality which is
gradually developed as the pulse- wave recedes from the heart. Now, he contends
that, if it depended wholly upon the blood being thrown into empty vessels, it
ought to be best marked in the arteries nearest the heart, as these are most
completely emptied during the diastole. By a series of careful observations with
the sphygmograph, he has succeeded in demonstrating the fact that the water-
hammer pulse occurs occasionally in cases where the aortic valves are healthy,
and that in others a tendency to it may often be seen in the tracings obtained by
this instrument from some of the smaller arteries. The same thing was seen in
the tracings obtained from the smaller tubes of a schema representing the arterial
system, made up of bifurcating elastic tubes and adapted to an artificial heart of
India rubber.
The author hence concludes that the transformation which the systolic portion
of the pulse of aortic regurgitation undergoes, and by which the quality of sudden-
ness is developed, is only an exaggeration to an extreme degree of a change which
takes place to some extent in the normal pulse. J. H. H.
1878.]
Public Health Reports.
213
Art. XXYI. Public Health Reports, and Papers presented at the Meetings
of the American Public Health Association in the years "1875-1876, with an
Abstract of the Record of Proceedings, 1876. Vol. III. 8vo. pp. 241.
3STew York : Hurd & Houghton, 187 7.
The present volume of this valuable series is made up of the more complete
and important papers presented at the meetings of 1875 and 1876. The essays
are skilfully grouped under certain general heads. An analytical table of contents
exhibits, under each heading, not only the subject of each article, but also a few
lines indicating the train of thought in each.
Dr. Austin Flint treats of Food in its Relations to Personal and Public
Health. Alimentation, unlike all the physiological processes dependent upon it,
is under direct voluntary control. The latter can be reached, aside from chugs,
only through the former. Mind and body, and even virtue and vice, depend on
proper nutrition. The chief aim of the essay seems to be to combat popular
errors as to the dangers of eating too much or too often. Appetite and liking-
are believed to be much safer guides than many people think. Variety, too, is
desirable. It is a mistake to suppose that a healthy stomach is strengthened by
confinement to a few easily digested aliments. Long intervals between meals are
usually anything but beneficial. Growing children are too often practically under-
fed, of course with baneful results. This usually proceeds from mistaken ideas
among parents and teachers. With girls, a feeling that a hearty appetite for sub-
stantial food is vulgar and unladylike, does infinite harm. The influence of
semi-starvation upon themselves and the next generation is as obvious as it is
deplorable.
Hon. Emory Washburn, of Cambridge, Mass., contributes a paper on Ex-
pert Testimony and the Public Service of Experts. The relation of this topic to
public health is perhaps rather remote. From the social and professional eminence
of the writer, however, we had reason to look for some new light upon a subject
so much discussed of late years, and with such differing degrees of wisdom. The
present effort scarcely meets our just expectation. The author disappoints us by
telling us only what has been already told again and again ; while he quietly
ignores the objections that haATe been urged against the course he proposes. His
confidence in expert testimony seems small at best, and he complacently echoes
the flings of English judges and writers. The actual exigencies, and the manifold
difficulties in the way of any attempt to overcome the recognized evils, are scarcely
noticed. The idea that appointment of experts by the courts would stop the vulgar
clamour against them, is hardly compatible with what we know of the disposi-
tions of men and the spirit and tendencies of English law.
A paper entitled Expert Supervision in Construction of Public Institutions,
which, as here presented, is very brief, yet contains most important facts and
suggestions. Dr. L. H. Steiner makes a very forcible and very just present-
ment of the inadaptedness, bad construction, unwholesome or otherwise objec-
tionable arrangements, which nearly always characterize, to a greater or less
extent, our buildings for public purposes. To avoid a continuance of morti-
fying blundering, he advocates the expert supervision of public institutions.
Each building erected for a definite purpose should possess an exact adaptation
to that purpose, whether it be as a school, a hospital, or a prison. Especially
should each and all be so ordered, that its inmates or frequenters shall receive no
injury from it. How well this obvious duty of the State toward the people is
performed, in building, or allowing to be built, jails, hospitals, almshouses, schools,
public halls, and even churches, we need not take time to inquire. The facts
214
Bibliographical Notices.
[Jan.
recently ascertained about our own city school-houses furnish sufficient and most
painful illustration.
The employment of expert supervision, rendered obligator}' by law, whereby
no structure for public purposes should be planned or built, except under the in-
spection of an expert, conversant not only with general sanitary principles, but
also with the special needs to be met, — this is the remedy here suggested for the
deplorable waste of money, health, life, and national resources, which Hows from
the gross ignorance and incompetence too often entrusted with the creation of our
public buildings.
Adverting to the important, and often very delicate questions, which arise from
the interference with individual liberty, exerted or proposed, by legislation in-
voked in aid of public health, Dr. J. S. Billings, in a paper entitled Rights,
Duties, and Privileges of the Community in relation to those of the individual,
in regard to health, exhibits the necessity of interesting and informing the lawyer,
as well as the physician, engineer, and architect, concerning sanitary principles
and efforts. In devising legislation, the assistance of a legal mind thus enlightened
would be most valuable.
Dr. Stephen Smith, of New York, contributes a most admirable exposition
of the Influence of Private Dwellings and other Habitations on Public Hygiene,
and the relations of Sanitary Authorities to them. Every family creates nuisances,
dangerous to itself and to its neighbours. Skilful appliances, intelligently super-
vised, can reduce the nuisance and the danger to a minimum. The doctor's
picture of the filth-engendering capabilities of a family is altogether too graphic
to be pleasant. His description of the emanations from the family wash, and
even of the appetizing fumes from the kitchen, is almost enough to make one
forswear civilized life forever. A forcible illustration of the influence of house-
hold uncleanness upon mortality is drawn from the results Avhich followed the
institution of sanitary inspection of tenement houses in New York. In these
dwellings the Health Board recently received power to exert effectual inter-
ference with whatever it deemed detrimental to public or private health. Into
the separate houses of separate families, however, it was not allowed to go,
except on special occasion. Notice the extraordinary result. One-hall* the popu-
lation of the city, living in the tenement houses, furnished, at the time the Board
began to exercise its almost despotic powers, 75.7 per cent., or more than three-
fourths of the total number of all the deaths in the city. This fell nearly 7 per
cent, the first year after the new measures, two more next year, and in five years
had become reduced to 64.8 per cent.
Strictly speaking, one would suppose the officials would have as much right,
and even obligation, to enforce the correction of disease-producing abuses in the
house occupied by one family as in that tenanted by many. Had the written
law not made this discrimination, how much greater had been the beneficent
work of the Board. For, while unwholesome conditions were doubtless more
numerous in the great aggregations of indigent humanity, it is notorious that they
are constantly found in the homes of the middle classes and even of the wealthy
and cultured. In England, the blood of royalty shows its common human weak-
ness by yielding to sewer poison in its own palaces.
The course pursued with such success in the tenements consisted in semi-annual
and special visitations, by which cleansing, white- washing, disinfection, proper
condition of drains and cellars, etc., were secured. In the one year following
the beginning of this system, nearly fifty thousand "ventilating windows" were
constructed in the houses of this class.
' ' Sanitary architecture in our dwellings, and sanitary supervision in their man-
agement," is a great want of to-day in American communities. No building
1878.]
Public Health Reports.
215
should be allowed until its plans and specifications have been examined and ap-
proved by competent sanitary inspectors. Certain prescribed requirements in
regard to drainage, heating, lighting, and ventilation would soon come to be
understood and met, even by ordinary architects and builders. But we are not
over sanguine as to the faithful enforcement of wise ordinances in these days of
demagoguery and municipal rottenness.
Under the head of Dangerous Employments and Harmful Processes, Professor
E. S. Wood, M.D., of Harvard, treats of Illuminating Gas in its Relations to
Health. Workmen in the retort house, which is rootless and freely open at its
sides, are exposed alike to great heat and to cold drafts. This, and perhaps the
dust of coal and coke, lead to a large amount of bronchial and phthisical disease.
The sulphuric and sulphurous acid formed by combustion of ordinary gas is
very injurious to plant life, and to many objects found in our dwellings. The
writer does not seem to regard them as injurious to human health. A variety of
gas made from water, and useful for heating, is condemned as excessively danger-
ous, being odourless, and containing deadly proportions of carbonic oxide. When
mingled with some petroleum product, as it is when adapted to illuminating pur-
poses, it acquires odour, and hence becomes much less dangerous.
Dr. Garvin, living among the gigantic cotton-mills of Lonsdale, R. I,, dis-
cusses Sanitary Requirements in Factories — Injurious Effects of Cotton Facto-
ries upon the Health of Operatives.
Accidents from machinery can, and ought to be, largely prevented by instruc-
tion and warning from the overseer, and especially by inclosing all cog-wheels,
belts, etc., which do not require to be exposed. Catarrhs, dyspepsia, anasmie
troubles generally, arrested or imperfect growth, and development, are the com-
moner results of mill-work, continued too many hours per week, and begun often
at a tender age. Infants suffer from the protracted deprivation of their natural
food and maternal care generally. The feeding of young infants on artificial food,
in order that the mothers may work in the mills," is justly characterized as little
less than murderous.
Acute diseases, except as occurring in infants, do not seem especially favoured
by factory life. But ailments dependent on debility and mal-nutrition, and espe-
cially upon continuous labour at an age which should be devoted to growth and
development of body and mind, are lamentably prevalent. Laws prohibiting or
limiting youthful labour have not been, but ought to be, most rigidly enforced.
A curious apparent anomaly is noticed in regard to the victims of consumption.
While English weavers, descended from generations of operatives, and lank,
stunted, or deformed, are far less likely to contract phthisis than dyspepsia, the
fresh and plump young Irish, just come from rural life, fade away with consump-
tion with alarming rapidity.
Three papers deal with the extremely important, though but little appreciated,
subject of Marine Hygiene. Writing of the Safety of Ships, and of those who
travel in them, the distinguished and efficient Supervising Surgeon General of the
Marine Hospital Service, Dr. John M. Woodworth, states that during 1875,
1502 American ships, and 85 foreign ships, on our coast, suffered disaster. Of
20,215 lives imperiled, 888 were lost. Wrecks, involving total loss, amounted,
ships and cargoes, to some ten million dollars. Similar facts relative to British
shipping are stated. With Mr. Plimsoll, Dr. Woodworth believes that a terrible
proportion of this loss is due to unseaworthy ships and unseaworthy sailors, in
other words, to preventable causes. Rigid inspection of vessels and men is per-
fectly practicable, and would be effective of much good. As already pointed out
in his Marine Hospital Service Reports, the medical officers of this organization
could be made examiners, before whom should appear every seaman offering him-
216
Bibliographical Notices.
[Jan.
self for shipment. Without their certificate of soundness, shipment should not
be allowed. Excessive competition in the carrying trade causes every effort to be
made to reduce expenses. Vessels go short-handed at best, and when part of
the creAv break down while at sea, the consequences may often be disastrous.
Laws exist providing for the inspection of steam vessels ; though in some cases
its execution has been but a farce — apparently from the corruption of the officers.
But, for sailing craft, nothing prevents owners from sending rotten ships to sea as
long as they continue to hold together. And when, finally, they fall to pieces or
become mere sieves, they are not apt to be safe in port.
Dr. Gihox, U. S. X., has an excellent paper upon the Need of Sanitary
Reform in Shij)-life. Air that is breathed over and over again and saturated
with animal exhalations, is the grand evil that destroys the sailor. And, to make
bad worse, it is a fact, incredible as it may seem, that in some of the finest ships
in our na^y the bilge is ventilated by gratings that open upon the berth-deck.
All decks, too, are by the tyrant custom of the service, deluged with water daily.
Phthisis and rheumatism, the two great scourges of the sailor, are the result of
this foul and damp atmosphere. Syphilis, worse than the former in that it is
indefinitely communicable, is borne all over the world in ships. The foul recesses
of forecastle and hold, and the indescribable filth of the bilge, form admirable
lurking-places for germs of zymotic disease.
These sources of disease are very largely capable of removal; but ignorance
and indifference in the merchant service, and the same, with the addition some-
times of the absurd, jealous arrogance of the average naval commander, in the
national ships, obstinately resist all efforts at improvement.
Thirty years ago, as Dr. A. X. Bell tells us, in a paper on Marine Hygiene
on board Passenger Vessels, emigrants to this country met with a frightful mor-
tality on ship-board. Ten deaths to the hundred passengers, he says, was con-
sidered a favourable result ; while twenty to thirty was not uncommon. Partly
owing to regulations established at the ports of departure, but much more to the
increased use of steamships, the days of such awful slaughter are past forever.
Of late years, the steerage deaths on steamers have been usually considerably less
than one in a thousand, while in sailing vessels, it has varied, from 18G4 to 1873.
between five and fifteen.
Very briefly, but suggestively, Mr. James T. Gardner, Director of the State
Survey of New York, points out the Relations of Topographical Surveys and
Maps to Public Health. Only when the prevalence of diseases shall be fully
and accurately known in connection with local conditions of surface, and subsoil,
and strata, can we comprehend the relations which exist, and become capable of
intelligent preventive action. The amount of moisture retained in a soil, for
instance, upon which largely depends the greater or less amount of certain mala-
dies, is determined by the combined operation of the surface configuration, the
character of the soil, the nature of the underlying rock, and the shape, form, or
slope of its strata. Combine the results of surveys, topographical, geological,
and sanitary, of a large area — and the writer believes that the principal causes of
disease will become obvious, and remedies practicable.
An essay by Dr. Ezra M. Hunt, of Xew Jersey, upon the Sanitary Appoint-
ments and Outfttings of Dwelling Houses, urges the necessity of keeping human
excrement out of the sewers, and counsels its removal by tubs or buckets. His
ideal system calls for sewers large enough to be freely patrolled, and containing a
tramway. Into the general cavity enter from each house waste water pipes.
From it a recess, or branch, passes beneath the sidewalk to the cellar or basement
of each house. Here, through a locked gate, the buckets or tubs are received,
placed in the car upon the tramway, while cleansed buckets are left in their
1878.]
Public Health Reports.
217
place. Other kinds of house-refuse, each in separate vessels, could be removed
in the same way. Of course, the key to the door from house to recess is kept by
the householder. If desired, another door, from sewer to recess, could be ar-
ranged, to be controlled by the sewer-police. As thus protected from exere-
mental contamination, the writer thinks sewage may safely empty into streams.
Dr. Elisha Harris reports upon Laws, Provisions, and Methods for secur-
ing the Benefits of general Vaccination throughout the Country. The lessons
drawn from foreign experience are noted, and suggestions made as to means by
which vaccination may be rendered systematic and complete.
In a recent epidemic of Scarlatina in Baltimore, Dr. John Morris finds
corroboration of the views advanced by Dr. Alfred Carpenter as to the power of
decomposing and diluted blood, from slaughter-houses, to give origin to this
disease. A very small stream of water received the drainage of several slaughter
houses, and after running a little more than half a mile became stagnant, in a
low place. (The writer does not state whether the brook is here lost or not.)
Water taken from this spot was disgustingly bad and putrid. Of a series of over
2000 cases, "East of Jones's Falls," the first occurred in this neighbourhood,
and the disease was very malignant and very fatal. One physician lost his first
five cases, on one street in this district. The vicinity of another creek similarly
defiled has been the seat of "a very large number of cases" during the past year.
Though not confining himself closely to Dr. Carpenter's idea of blood as alone
furnishing the specific poison, the writer is disposed to believe that the virus arises
from animal matter decomposing under certain conditions.
C. T. Lewis, Esq., Secretary of the Chamber of Life Insurance, New York,
contributes a scholarly essay in which he contrasts the Hygiene of Ancient and
Modern Times, and exhibits the Influences of Civilization on the duration of Human
Life. In the ancient civilizations the State, or Society, was paramount. The
individual must ever yield himself to the public. Early Christianity magnified
the importance of the single man. Modern civilization reconciles and blends the
two purposes into one. For, though the two principles seem to be, and perhaps
upon a limited view really are, conflicting, yet in the wide field of human progress
they are in perfect harmony.
Some of the more obvious and powerful causes leading to greater mean longevity
in the human family are thus noted : the better care taken of infants, and also of
the. sick, infirm, and aged ; the control acquired over epidemics, as the plague,
cholera, scurvy, and many others, and eminently the smallpox ; and, finally, a
class of agencies which may be designated as hygienic and sanitary reforms
generally.
To those who would find in natural evolution, by survival of the strongest, a
sounder mode of progress for the race, our author points out the enormous cycles
of ages required thus to bring men even to the condition in which we find them
to-day in Borneo, Australia, Xew Zealand, and Patagonia. Do these results
compare favourably with the work of civilization, as achieved during that single
movement of the world's second-hand, which we call the period of authentic
history ? Among the races just named, man is old at forty, and dead or decrepit
at fifty : while female beauty, at its height at fifteen, begins to decay at twenty-
two. Wherever man enters upon any progression different from that of the
brutes, it is by the influence of individual and hereditary culture superseding
natural selection. Intellectual and moral forces rule where once mere animal
power held sway.
Treating of Summer Resorts for the Debilitated Children of our Cities, Dr.
Jerome Walker shows that experiments already made have fully proved the
very great usefulness of country and seaside air, even if for but a few weeks or
218
Bibliographical Notices.
[Jan.
even days, in preserving the lives of this class of our population. It seems, too,
by no means impracticable to provide sanitary villages in healthful rural district-,
to which temporary colonies of city poor could be successively sent during the
hot months. Probably, however, a greater and more lasting good may be effected
by enabling the poor to live in the country, with cheap transportation to their
city work. Will not some George Peabody build a model village, near a great
city, with cheap railway connection V
In a report upon hospital ventilation, Carl Pfeiffer hits the nail squarely
on the head when he concludes that only by "forced ventilation" — preferably
by a fan driving fresh air in — can purity of atmosphere be secured at all times
and seasons. It is more than twenty years ago that the immense superiority of
this method was established by the most conclusive competitive trials and experi-
ments under the observation of such men as Pettenkofer, Grassi, Peclet, and
Seifert. Morin, a great advocate of the aspiration method, confessed its infe-
riority after observing the two systems side by side in two halves of one building.
The experience of American hospitals for the insane has taught the same lesson.
It is not designed to maintain that aspiration never gives fair, or even excellent,
results ; but, simply, that in effectiveness, uniformity, and certainty, it cannot
compete with propulsion.
Referring to the fact that what we call "sewer gas" has proved insusceptible
to analvsis, or to identification as any given chemical combination. Prof. TV. H.
Br ewer, of the Scientific School at Yale, in a paper entitled the Gases of
Decay, and the Harm they cause in Dwellings, etc., ventures the hypothesis
that decomposing gases may contain and support organic germs, just as liquids do
infusoria. Several considerations, not needful to be here repeated, seem to indi-
cate that the effects produced by sewer gas are not of a character analogous to
those known to proceed from any gaseous compound simply. Typhoid fever,
originating from poison borne on the emanations from a sewer, is liable to be
passed on from the original recipient to others. No one supposes that the gas,
as such, can be handed on from one human body to another. There seems to be
no reason why certain gases, or mixtures of gases, in a state of change, should
not support and nourish peculiar organic germs, just as decomposing fluids are
known to do.
Prof. Horsford, of Cambridge, has hit upon the "happy thought" of a New
Profession in the Service of Hygiene. He would have a man well taught in
mechanics, physics, hydraulics, chemistry, and in all sanitary lore, who should
be called in to relieve those numberless miseries which so grievously afflict, in
our day and generation, the dwellers in houses " with all the modern improve-
ments." Whether the Professor writes in joke or in earnest we are not sure;
but that, in all our cities, men who should fill the requirements here sketched
would earn fat fees and immeasurable gratitude, we feel quite certain.
Recognizing the very great need for the Popularization of Sanitary Science,
Prof. Claypole, of Antioch College, regards the schools as the best means
available to this end. But to make such teaching vital and efficient in the public
schools, teachers must be far better grounded in the theory and practice of hygiene
than they now are. Improvement must begin at the top. Universities, acade-
mies, and normal schools must send out their graduates endowed with some
acquaintance with the conditions which make for health or for disease in the habits
of the individual and in the structure and surroundings of the school, the home,
and the city. And the authorities which build school-houses must be forced to
make them what they should be, and no longer allowed to stunt, and stifle, and
blind, and poison the precious charge confided to them.
1878.] Laxgexbeck, Gunshot Wounds of the Hip-joint. 219
George E. Waring, Jr., sanitary engineer, points ont the errors and dangers
most liable to attend country houses, even of the more expensive class. We need
hardlv say that it is from the disposal of refuse and excrementitious matters, as a
first cause, that nearly all these actual or threatened ills arise.
Some half a dozen articles we omit to notice, not so much for any want of
interest or value, as because their teachings have come before our readers in other
connections.
The work is handsomely printed on heavy, tinted paper, by the Riverside
Press ; is substantially bound in cloth. In both matter and form it is a creditable
and useful book. B. L. R.
Art. XXYII. — Surgical Observations on Gunshot Wounds of the Hip-joint.
By B. Vox Langenbeck, Professor of Surgery in the University of Berlin,
etc. etc. Translated by James F. West, F.R.C.S., Senior Surgeon to the
Queen's Hospital, and formerly Professor of Anatomy in Queen's College,
Birmingham. 8vo. pp. viii. 63. Birmingham: AYhite & Pike, 1876.
As the result of his experience during the Franco- Prussian war, Professor Yon
Langenbeck has contributed to surgical literature two essays, the first of which,
on Gunshot Wounds of the Hip-joint, has been translated by Mr. West, of Bir-
mingham, who also promises to do the same kind office by the second essay,
which is entitled, t: On Resections as seen in the light of then Results." The
first essay, the one with which this notice has to do, was originally read at the
first German Surgical Congress, and bears abundant marks of that thoroughness
of investigation, which, when exercised upon ample material, leads to the ex-
haustiveness so often possessed by German monographs. Langenbeck' s first
intention was to speak of gunshot wounds of joints as a whole, but rightly con-
sidering that the special questions which arise in connection with the individual
joints were such as to prevent the laying down of any abstract principles of gene-
ral treatment, he decided to contract his scheme, and has confined himself to the
discussion of gunshot wounds involving the hip-joint.
Statistics hitherto obtained, in Langenbeck' s judgment, are not sufficient to
establish with accuracy the principles upon which gunshot wounds of the larger
joints should be treated ; nor, from the nature of the case, is this state of things
likely to be soon changed, or statistics, suitable to found accurate generalizations
upon, collected. While thus condemning the bulk of our statistical inquiries,
the Professor is particular to inform his readers that the defects are in no great
degree the fault of observers, but are attributable to the exigencies of military
surgery. The sudden accumulation of severely wounded, and the inevitable con-
fusion attendant upon a great battle, must ever present great difficulties against
that thorough study and primary classification upon which the appropriate treat-
ment of each case of hip-joint wound must depend.
The important question in all wounds of the hip-joint is to determine which
case will be best treated upon the expectant plan, which demands, or will de-
mand, operative interference, and, should resection or amputation be required,
to decide when the operation shall be performed. It is just here that the special
characteristics of each case are of paramount importance. It is this all-important
primary knowledge that the military surgeon finds it so difficult or impossible to
obtain as the result of his own observation, and it is to contribute to our stock of
knowledge on these particular points that the distinguished Berlin Professor has
written this brochure. Hitherto' surgical literature has recorded most unhappy
220
Bibliographical Notices.
[Jan.
results from gunshot wounds of the hip-joint, so much so that it has appeared to
be a matter of little moment what treatment was adopted, as the few recoveries
were pretty evenly distributed between the expectant and the operative plans,
and were always rare exceptions. The very hopelessness with which these cases
were regarded has contributed its share in preventing military surgeons from
giving close attention to the primary examination of them, and our author is
most imperative in insisting that upon this primary examination, and the adop-
tion within twenty-four hours of a line of treatment based upon an accurate dif-
ferential diagnosis then obtained, must, in very large measure, depend the (prospect
of a successful issue in each individual case. He further undertakes to show that
in the Franco- Prussian war, while not a few cases of hip-joint wounds resulted
favourably under conservative treatment, many more would have done so had an
accurate and early diagnosis been made ; on the other hand it is shown that ope-
rative interference became an immediate duty in many cases.
Proceeding to the consideration of special points, Von Langenbeck pronounces
most decidedly against the existence of non-penetrating wounds of the hip-joint;
says he has never seen one in the whole of his long experience ; and thinks that
their occurrence, if not incompatible with the high rate of velocity of missiles
from the arms of precision now in use, must be very rare. The old rule for
locating the joint is endorsed, and we find the following definitive formula : "If
the entrance or exit of the shot, or the direction of the shot canal encroaches
upon a triangle whose base intersects the trochanter major, and of which the
femur and anterior-superior iliac spine form the points of an acute angle, the joint
will probably be implicated." Gunshot wounds of the trochanter major are
always serious injuries, and should invariably be treated as wounds of the joint,
for splintering of the neck of the bone is commonly attendant upon them. A
bullet striking upon the centre of this process may traverse the neck of the femur
and enter the joint, while the elasticity of the cancellous tissue may cause it to
close so completely over the track of the modern small missile that no probe can
be made to follow by any allowable use of force, and the ball may be thought to
have rebounded and dropped out when it is in reality deeply lodged. Two cases
are related in which this state of things existed, and both ended fatally. The
wound of the joint may be masked by the ball coming from within, and reaching
the joint after traversing the bladder, or rectum, or both. In two cases where
the bladder was thus involved, recovery under conservative treatment is noted.
Referring to Simons' s experiments, which proved the possibility of a bullet
passing between the articular extremities of the femur and tibia without injury to
either bone, a remarkable case is detailed, in which a bullet, after breaking off a
piece of the inner edge of the acetabulum, opened the joint, perforated and split
the acetabulum, and in its further passage onwards wounded the bladder without
injuring the head of the femur. This case can only be explained by supposing
that the admission of air forced the joint surfaces apart sufficiently to allow the
missile to pass between them. Lodgment of the ball is a very unfavourable com-
plication, as all experience shows, and general reasoning would lead us to expect.
In thirty-two fatal cases the ball lodged in no less than twenty-six, while in
eighteen cases of recovery the ball remained in only seven times.
Coming next to the symptomatology of these cases we first notice that we may
expect complete fracture of the neck of the femur to have the same characteristic
evidences of deformity as exist in simple fractures, but experience has shown
that considerable injury of the bones may be sustained, and the joint may be
opened, and yet the patient present nothing in his appearance to suggest that
he is suffering from more than a flesh wound. Many wounds of the hip-
joint have thus been overlooked at the very time when it was all important that
1878.] Lang en beck, Gunshot Wounds of the Hip-joint.
221
the precise nature and extent of the injury should have been known, and, either
an immediate resection been done, or conservative treatment decided upon, while
in either case further transportation should have been positively interdicted, and
absolute rest enforced. The absence of synovia cannot be relied upon as a diag-
nostic sign, as it is often not seen, though the joint be opened ; and especially is
this the case when the ball enters back of the groin ; on the other hand its
presence is of course conclusive evidence that the joint is implicated. A most
valuable sign is swelling of the articular capsule, which may be caused by blood,
synovia, or other fluids, distending the capsule, or by swelling of its own tissue.
It is most readily detected in front, where the muscular planes formed by the
adductors will show distinct interruptions. The enlargement of the capsule may
be sufficient to push the femoral vessels forward until their pulsations will be felt
just beneath the skin. This symptom is regarded as particularly important, and
we are told that it will generally be more evident as the entrance wound is more
distant from the joint, as thereby the escape of morbid products is made more
difficult.
With the progress of inflammation the ordinary symptoms of coxitis, only in-
tensified in degree, will be observed ; but it must not be forgotten that, under
favourable conditions, a gunshot wound of the hip-joint, where the bone injury
is slight, may heal without coxitis. When inflammation is suddenly set up
within the joint, some time after the receipt of the injury, a favourable prognosis
may generally be made. In those cases where the capsule is wounded and dis-
tended with blood, inflammatory symptoms will occur earlier, in from seven to
fifteen days, than where the inflammation is secondarily induced by injury of the
bones. While fissures may heal without trouble, it is their occurrence which
makes injuries of the trochanter major so serious, and they are often the origin
of osteo-myelitis.
The well-known fact that injuries of the soft parts in the immediate neighbour-
hood of the joint often lead to inflammation of it is confirmed by Langenbeck,
who further declares that wounds of the iliac bursa, owing to the proximity to,
and the communication with, the joint, which generally exists, should always be
classified as joint wounds. The tendency to flexion of the femur upon the pelvis
is well marked where suppuration in the joint is established, and spontaneous
luxation sometimes occurs; but, in Langenbeck's opinion, it is almost always
downwards and forwards, and very rarely on to the dorsum ilii. Anchylosis is
the constant result of curable gunshot wounds of the hip-joint, and although in
wounds of the capsule, in which the inflammation has been kept within narrow
bounds, recovery with more or less perfect motion may ensue, the aim of the
surgeon should always be to favour anchylosis. While in many cases in which
life was preserved, but a useless limb remained, others are recorded in which a
useful extremity resulted; and Langenbeck's experience has taught him, as that
of others has taught them, that a deficiency of one or two inches in the length of
the limb is but a trivial one, easily obviated by the yielding of the pelvis and a
thick sole. When the loss is greater it is very often an illustration of the imper-
fect treatment which yet obtains too often in these cases.
The danger of wounds of the hip-joint is well known, and has been attested by
the sad experience of all military surgeons ; but Professor Von Langenbeck points
out one risk which is, perhaps, not usually recognized, namely, that from the
density of the enclosing capsule, and the deep situation of the joint, surrounded
as it is by powerful muscles, the tendency to retain wound secretions is very
great, and in consequence there is increased liability to septicaemia. Out of
thirty-nine cases in which the cause of death is mentioned, in no less than thirty-
four did it result from septicaemia or pyaemia, while in three others it was caused
222
Bibliographical Notices.
[Jan.
by venous thrombosis. In general terms, the danger is proportioned to the ex-
tent of bone injury and the general concussion of the parts. If accumulation of
matter is not allowed to take place, simple wounds of the capsule, or those unac-
companied by important bone injury, allow of a tolerably favourable prognosis,
nine out of thirteen cases recovering. Where the bone injury is proved, and ex-
tensive, a very unfavourable prognosis must be given, there being but eighteen
recoveries out of seventy-five cases cited in this tract. The statistics of the
Franco-Prussian war, however, go to show "that hip-joint injuries are not abso-
lutely hopeless." In all the cases treated by the conservative method, the per-
centage of deaths was 71.59, and in resections the death percentage was 83.87.
The totals respectively given by Langenbeck are eighty-eight and thirty-one.
This heavy ratio of fatal results may reasonably be expected to diminish, as the
importance of early and accurate diagnosis is appreciated and acted upon by
military surgeons. At least this is the anticipation of the distinguished author of
the pamphlet.
When there is doubt as to whether there is serious injury of bone, the prefer-
ence should be given to conservative treatment ; but it is not applicable, and
should not be relied upon, when there is complete extra- or intra-capsular fracture
of the neck. In such cases, or where injury of the acetabulum causes retention
of secretions, resection should be resorted to despite the great mortality attending
the operation, and this mortality Langenbeck does not hesitate to prophecy will
become less as surgeons resort to it, as they do to amputations, within one day of
the receipt of the injury. The long incision is advised when resection is to be
resorted to, and unnecessary removal of the trochanter major is strongly repro-
bated. Disarticulation is only to be thought of as a primary operation, and if the
proper moment for its performance is past, it is better in extensive gunshot frac-
tures to do a preliminary resection, in the hope that at some future time the pa-
tient may be in a condition to bear an amjmtation. This plan is thought by Lan-
genbeck to receive strong support from the statistics of reamputations collected
during the Rebellion in this country.
The successful conservative treatment of wounds of the hip-joint depends largely
upon two things, immobilization of the joint and weight extension, and where
they can be properly applied and maintained from the first much is accomplished
in cases which ought to be curable. But it is very difficult, often impossible, to
fulfil these indications upon the battle-field, where only the apparatus most easily
applied and most readily transported is to be obtained. Xor is it always practi-
cable to sift the cases and spare the most serious ones further carriage by keeping
them in field hospitals, for field hospitals themselves will often require to be re-
moved, experience having shown that considerations of strategy will ever out-
weigh the claims of the Geneva cross. Much has been done to alleviate the
miseries of war and the sufferings of the wounded ; but to press the claims of
humanity, in the face of men frantic with excitement and straining for victory, is
futile ; they are freely hazarding their own lives, it is hardly to be expected that
they will regard those of others. The Geneva Convention has accomplished,
will yet accomplish, much ; but war and humanity, like fire and fuel, exist to-
gether only in the destruction of one by the other. As this notice is written, the
same sad tale is repeated from the ancient parts of the earth, and from the birth-
place of the human family come mutual recriminations concerning the treatment
of the wounded. Seeing, then, that the Geneva Convention cannot accomplish
all that was hoped for by its originators, Langenbeck thinks that the energy and
inventive genius of military surgeons must be directed to devising such apparatus
as will best enable us to transport patients suffering with wounds of the lower ex-
tremities in a state of immobility, immediately after the first dressing. Plaster cf
1878.] Langenbeck, Gunshot Wounds of the Hip-joint.
223
Paris bandages require too much time and too many skilled attendants, and some
form of light splint is most desirable. In our author' s judgment Bonnet' s wire hose
are too bulky to be carried into the field, and in the after-treatment are too difficult
to keep clean. After referring to several others, he settles down in the opinion
that the Austrian zinc splints of Sehon are likely to best suit the indications. The
second essential element of successful treatment of hip-joint wounds, extension by
a weight, can be readily applied at a field hospital, and should be kept up from
the moment of its first application until the anchylosis is sufficiently firm for the
patient to walk with the joint guarded by an immovable plaster or paste bandage.
Unnecessary probing of the wound should be avoided when it is intended to
pursue a conservative course, as thereby additional irritation and often renewed
hemorrhage may be excited, by which the possibility of the shot canal healing
without suppuration is diminished. Dilatation of the wound may, however, be
very properly practised when there is retention of secretions, and in conjunction
with the incisions necessary to a thorough investigation of the condition of the
parts, must always be resorted to whenever the question of operative interference
is entertained. Bone splinters should be removed when they lie loose in the
track of the wound, or when their presence is likely to obstruct the discharges
therefrom ; but repeated and vigorous attempts to remove them in recent wounds
are injurious, venous thrombosis being more apt to occur after such measures,
while the liability to infiltration of the surrounding parts, and the subsequent ab-
sorption of morbid products, is increased. On the other hand, free incisions made
early are of great value in facilitating the discharge of fluids, and are too often
neglected or deferred too late. When infiltration has occurred, and septicaemia
has set in, they are useless. Should the incisions made to evacuate matter reveal
an overlooked fracture, Langenbeck would prefer to continue treating the case on
the expectant plan, and under no circumstances would he attempt or advise the
performance of a resection until the fever had subsided. As might be anticipated,
the German treatment of recent joint wounds by ice is preferred to that by cata-
plasms, recommended by Dupuytren, and generally followed by French surgeons.
With the antiseptic method of Lister our author has had little experience, but
that little has been so favourable to it as to lead him to think that it will ulti-
mately prove of great value in properly selected cases ; that is, in those where the
extent of bone injury is slight, and the surrounding circumstances are suitable for
carrying out conservative treatment.
The cases upon which, in large measure, the conclusions of this pamphlet are
based, are grouped in tables at its end, a method which, from the facts that the
thread of the argument is preserved and that better facilities are afforded for
reference, strikes us as much better than that of interpolating them in the text.
Xo. I. gives brief histories of twenty-five cases successfully treated on the con-
servative plan. Table II. gives sixty-three cases which, under the same plan of
treatment, resulted fatally. Table III. comprises all the cases in which resection
of the head of the femur was done, thirty-one in number, of which four recovered,
in one the result was unknown, and in the remainder death ensued. In Table
IV. will be found thirteen cases of disarticulation of the thigh, and, in all, the
uniform result was death. In these tables sufficient details are given of most of
the cases to make them worthy of special study. The English translator has
added in an appendix an abstract of the cases recorded in Circular No. 7, con-
taining the results of our own experience in the late Rebellion.
It may seem as though the length of this notice was out of all proportion to
the size of the pamphlet noticed ; but this essay claims attention alike from the
eminence of its author and the importance of its subject. Many a portly volume
which requires laborious investigation to ascertain and master its contents, can be
224
BlBLIOGRAPHICAL NOTICES.
[Jan.
summarized in a few sentences ; but this modest little tract presents an array of
observations which could hardly be analyzed in less space than we have given to
it. Baron Yon Langenbeck has too robust a constitution to resort to padding,
and he has given, in somewhat crude form, a model of condensation which many
might well follow.
The translator appears to have done his work well, and in the preface has
taken notice of the labours of our own Surgeon-General's Office in appreciative
words of eulogy. In presenting this treatise to English and American readers,
Mr. West has done a good thing for surgical literature. S. A.
o o o
Art. XXYIII. — Retarded Dilatation of the Os Uteri in Labour. By Albert
H. Smith, M.I).. Lecturer on Obstetrics to the Philadelphia Lying-in
Charity. 18mo. pp. 46. Philadelphia, 1877.
Dr. Albert H. Smith is always sure of a prompt and attentive hearing on
the part of his professional brethren, for his contributions to obstetrics and gyne-
cology are always plain, practical, and bear the impress of personal experience.
Even though the presentation of his views should not invariably cany conviction
of their truth to all, nevertheless any dissent will always be respectful, if not
qualified and partial.
The first part of this pamphlet is devoted to Delays from Conditions of
the Cervix; the second to Delays from Absence of Dilating Wedge. The
first branch of the subject is considered under the two heads of active and
passive rigidity of the os uteri. Dr. Smith gives a graphic description of
active rigidity, or spasmodic contraction of the mouth of the womb, and advises
as first in importance of all remedies, opium. He then passes in review
anaesthetics, chloral, tartar emetic, bleeding, and incisions, rejecting them all.
But is not this too absolute, too unqualified a rejection so far as at least some
of these therapeutic means are concerned ? Certainly some obstetricians have
found cases where chloroform or ether inhalations have done excellent service in
spasmodic rigidity, and believe the difficulty has been vanquished sooner then
than it could have been by opium. Dr. Smith refers to anaesthetics as "safe in
cautious hands, given merely to relieve pain without causing profound stupor."
But profound stupor, scarcely stupor at all, is desired or desirable in such cases.
Again, he tells us that these agents diminish the force of uterine contractions, and
hence inertia in the third stage of labour may result. Conceding this diminished
uterine force, is there not likewise a more than compensating diminished uterine
and perineal resistance, and may not the shadow of uterine inertia which seems
to darken the third stage be dissipated by ergot opportunely given, and, more
than this, by the proper delivery of the placenta? There seems to be a sort of
ill-defined dread of anaesthetics in labour, manifesting itself in certain quarters,
a dread which the utterances of such a master as Dr. Smith we fear will too much
increase. On the other hand, we are glad to see that in a paper1 presented at the
International Medical Congress, held at Geneva, in Sept. 1877, by M. Piachaud,
its author asserts, among other conclusions these, that anaesthetics susj^end neither
uterine nor abdominal contractions, and that they lessen the natural resistance
of the perineal muscles ; and that their employment is indicated in cases of
1 Archives Generales de Med., Nov. 1877, p. 625, and Monthly Abstract of Medical
Sciences, January, 1878.
1878.] Smith, Retarded Dilatation of the Os Uteri in Labour. 225
natural labour whenever the labour is delayed or suspended by suffering from an-
terior maladies, or supervening at the time, and in cases where irregular and
partial contractions occasion local and almost constant pain without contributing
to the progress of the labour. Courty, in his remarks upon the paper, asserted
that chloroform was not indicated in cases entirely normal, but only when the
pains were very severe and irregular, and when the patients desired its use ; it
diminished the duration of labour almost one-half, and by so much lessened
traumatism, and it offered the combined advantages of chloral and ergot.
Dr. Smith rejects chloral on the grounds that it is more prostrating in its after-
effects than opium, and less controllable than the vapours of ether or of chloroform.
On the other hand, a recent obstetric writer (Play fair) asserts that "chloral is
the remedy par excellence," — so widely will doctors differ! So, too, the tartar
emetic which Dr. Smith rejects, finds a firm supporter in Dr. Meadows.1 Xot a
word can be said except in commendation of the positions the author takes as
to bleeding and incisions in the treatment of spasmodic rigidity of the os uteri.
In considering ' ' the second form of rigidity, the passive, or, as Dr. Hodge has
called it, the physical," Dr. Smith remarks : —
"This is not a mere functional condition, dependent upon constitutional causes,
but is a genuine rigidity, a want of extensibility, dependent upon tissue pecu-
liarities. It may vary from the simple firmness of tissue found in the cervices of
many primiparae of advanced years, as a want of true physiological softening, to
the cartilaginous hardness of a fibrous or malignant degeneration. Unlike the
intermittent paroxysmal condition of which we have been speaking, attended
with general and local symptoms of nervous and vascular derangement, it offers
a continuous resistance ; the os uteri is natural in its character ; its margin round
and well developed."
Xow it is difficult, impossible, to understand how the os uteri can be "natural
in its character" with "the cartilaginous hardness of a fibrous or malignant de-
generation." That classification of rigidity of the os uteri which embraces but
two divisions is obviously imperfect. Neither as to pathology nor as to thera-
peutics can the rigidity dependent upon cartilaginous hardness of fibrous or of
malignant degeneration be included with that where the os is natural. The
divisions which Dubois made seem to us preferable to Dr. Smith's; they were
pathological rigidity, spasmodic, and anatomical, or, as Pajot terms the last,
mechanical. Cases where there are such structural alterations as we have quoted
from Dr. Smith, would be included in the first of these classes.
In the treatment of "passive rigidity," the author includes "means to soften
the indurated tissue," and those " to force open the os." He regards the most
valuable of the former a douche of water at a temperature of 105° to 110° F.,
by a Davidson's syringe, the douche to be repeated every hour or two as long as
necessary; while the simplest of the latter is 11 traction by the finger upon the
anterior lip, a procedure useful in almost any case of labour not attended by spas-
modic rigidity."
From Scanzoni's statistics we have learned that, in 4000 labours, there occurred
ten cases of the form of rigidity we are now considering, while there were rather
more than fifty of spasmodic rigidity ; we cannot help thinking that, if this digital
dilatation which is pronounced so useful becomes the rule in obstetric practice in
perfectly natural labours, the difference will be still greater, the number of cases
of spasmodic rigidity be much increased. When obliquity of the uterus delays
dilatation, drawing by the finger the os to the pelvic axis during "a pain," or
where the presenting part is "hooded" over by the anterior lip, similarly lifting
off that hood, it seems to us are the only proper uses of the finger in assisting in
1 Manual of Midwifery. Philadelphia, 1S76.
No. CXLIX Jan. 1878 15
226
Bibliographical Notices.
[Jan.
the first stage of normal labour. We remember very well what the oral instruc-
tions in this regard were of one of the greatest of American obstetricians, the
late Dr. Hodge, and we find in his printed words the following:1 " If the os uteri
afford undue resistance, no mechanical measures should be adopted, such as pres-
sure or traction by the fingers, as recommended by some physicians," etc.
After pointing out the value of traction in this form of rigidity, Dr. Smith
passes to the consideration of India-rubber dilators, giving a very decided pre-
ference to those of Barnes, and wisely insists upon always using water for their
distension. We have generally used the Molesworth dilators, partly because of
their easy application, and their less liability "to get out of order," but doubtless
Dr. Smith's preference for the others is just.
"After dilatation has progressed far enough," says Dr. S., "we have an ad-
mirable aid to dilatation in the obstetric forceps." We apprehend that here Dr.
Smith will meet with the greatest number of dissenters from his teaching, for the
practice advised is so contrary to one of the fundamental rules hitherto laid down
by almost all teachers of obstetrics. Dissent, indeed, he seems to have been pre-
pared for, since he makes a plain and strong defence.
Now it is not necessary to seek from Duparcque or Yelpeau, or any other of
older authors, illustrations of ruptures of the uterus from the application of the
forceps, the os being undilated, for we have at hand a recent authority whose
statement is quite sufficient. Winckel2 includes in the etiology of ruptures of the
uterus, " the premature application of the forceps with an imperfectly dilated os ;
the edges of the blades then cut the lips of the os in different places as they
slide off ; this mode of occurrence I have frequently seen, and have published one
such case." Nevertheless, Dr. Smith's practice has a good foundation, not only
in his own experience but in the teaching of Dr. Barnes more than seven years
ago. The latter spoke as follows : — 3
"When the forceps will pass — and it is quite possible to apply it when the os
will allow three fingers to pass as far as the knuckles — this instrument may serve
to dilate further. But this must be done with great caution. The head being
grasped, you may draw steadily down, and, by keeping up gentle traction, the
wedge formed by the blades and the head will gradually dilate the os, perhaps
enough to allow it to pass, and thus save the child's life."
So, too, Dr. Smith is confirmed in his position as to the use of the forceps by
the recently published experience of Dr. Isaac E. Taylor.4 In a most interesting
paper read before the New York Academy of Medicine, this accomplished obste-
trician narrated the successful use of forceps for dilating the os. He gives a
representation and description of what he terms his small forceps, the width of
the blade being one inch and three-eighths ; using this when the dilatation of the
os was less than two inches, in fifteen or twenty minutes the dilatation permitted
the application of a stronger and larger instrument. He states that in some of
the cases of this early application of the forceps, "the object was simply for
the instrument to retain the head of the child in contact with the os uteri during
and after a pain, and in some cases aid in flexing the head when the vertex pre-
sents, so that the occiput may be put in apposition with the os tinea?, and thus
become the natural dilator of the cervix."
In the light of these quotations there would be less hesitancy, if any at all were
felt before, in following Dr. Smith's practice. Moreover, it will be observed that
1 System of Obstetrics.
a The Pathology and Treatment of Child-Bed; translated by Dr. J. R. Chadwick,
Philadelphia, 1876.
3 Obstetric Operations.
4 What is the Best Treatment in Contracted Pelves. New York : D. Appleton & Co.
1878.] Smith, Retarded Dilatation of the Os Uteri in Labour. 227
Dr. S. recommends the forceps of Davis or of Hodge. ~Now we must think that
when the os is sufficiently dilated for the easy application of the Davis forceps
for example, it is so well dilated that the head will not tarry long in its exit
if there are vigorous uterine contractions. So, too, the introduction of forceps
within the uterus has something more than a mechanical effect, not merely dila-
tation and traction that are accomplished with the instrument ; it has, as so well
pointed out by Tarnier', a dynamic action, "the introduction of the instrument,
sometimes of one of the blades only, stimulates the uterus and arouses contraction
so energetic that sometimes the expulsion of the infant takes place without
uniting the blades or exerting any traction." May not this dynamic action be
as important an element of the success of his practice as either dilatation or
traction ?
We think it best to give the author's own words as to the forceps and their
mode of use, and therefore give the following extract from the author's pamphlet.
" They must be forceps having blades of a shape to fit closely to the head, not
increasing the bulk of the cranium in passing through the cervix, allowing the
soft tissues of the head to bulge through the fenestras and protect the uterus from
any pressure ; they must, therefore, have oval fenestras, upon the Hodge or the
Davis model ; they must be applied conscientiously to the sides of the head (the
only uniform surfaces adapted to receive the uniform concavities of the blades)
in the direction of its long axis ; and traction must be made in imitation of nature's
efforts, the force from before being simultaneous with, and precisely similar in its
action to, the force from behind ; the uterus and the forceps must act together
and alike ; the traction must be in the line of the pelvic axis ; it must be inter-
mittent ; it must be direct, with no contusing lateral movement ; and if these
conditions are fulfilled, there can be, I assert fearlessly, no more danger to the
uterine tissues from the head coming through in the grasp of the forceps than in
passing without them. When, then, the os uteri is sufficiently dilated to allow
the introduction of the blades, they may be carefully applied, and during each
uterine contraction the head may be drawn down gently, and with as little com-
pression as may be required to keep the blades in place. We have then nature's
own dilator, supplemented by art simply for the increase of its powers, without
any change in the method of action, no new plan of operation being introduced."
Having devoted so much space to the consideration of the author's treatment
of delays from conditions of the cervix, we shall only briefly notice that of delays
from absence of presenting wedge.
Dr. Smith divides these delays "into those which depend upon causes con-
nected with the contraction of the uterine body and those resulting from faulty
relations of the presenting mass with the pelvic strait."
The agent in which he has the most confidence in simple inertia of the uterus
is quinia ; the form preferred is the bisulphate, and the dose fifteen grains. Fur-
thermore, he states, "1 do not hesitate to give it in every case, because, even
when there is no decided inertia at the onset of labour, there may be a failure
of the powers of the mother, from early exhaustion and fatigue, and we get the
benefit of the quinia in diminishing this tendency and also in promoting the conden-
sation of the uterine fibre after the delivery of the placenta," etc. While heartily
agreeing with Dr. Smith as to the value of quinia in certain cases of ante-partum
uterine inertia, we are not prepared to believe in the common use of this agent
in cases of parturition ; indeed, such wholesale application, and the argument for
it seems very much like the punishment inflicted by an angry Teuton upon his
silent son for thinking profane words!
A just, and possibly needed, warning against the use of ergot is given, and the
respective forms of inertia from excess of liquor amnii, from irregular contrac-
1 Nouveau Dictionnaire de MeJecine et de Chirurgie Pratiques, vol. xv.
228 Bibliographical Notices. [Jan.
tion and from premature labour are considered, and their appropriate treatment
presented.
" The remaining class of cases in which there are conditions interfering with
dilatation of the os in labour, are those depending upon the relation of the pre-
senting mass to the pelvic brim ; the cases in which, although the labour- pains arc-
vigorous and regularly recurring, and the os soft and dilatable, the foetus, being
prevented from dipping down into the pelvic excavation, cannot impinge upon
the rim of the os, and necessarily cannot act mechanically in effecting its dilata-
tion. These may consist either (l) of cases in which there is a want of corre-
spondence in the measurement of the pelvis and of a normally presenting foetus
(i. e., where there is a large foetus, or a small pelvis), or (2) of those in which,
with ordinary size of both, the foetus may be unfavourably placed for entering the
brim."
Omitting cases of mal-prescntation, as well as those of marked pelvic or foetal
deformity, the essential treatment Dr. Smith advises is the application of the
forceps, which should be applied as soon as the os is sufficiently dilated. He
especially dwells upon the value of this instrument for effecting complete flexion
in occipito-posterior position.
We have now completed the review of Dr. Smith's very interesting and valua-
ble contribution to obstetrics, and yet we cannot close without a gentle protest
against the form and type. Bourgeois is not pleasant for the eyes, at night espe-
cially, while an 18mo. is an exceedingly inconvenient form for preservation. A
pamphlet of this size may wait in a physician's office almost a lifetime before
enough of like linear riches may be added to it to make a volume for binding.
The importance of the subject and the ability of its discussion demanded a pam-
phlet of better appearance than this ; a pamphlet handsome in form, easy of read-
ing and of preservation. T. P.
Art. XXIX. — A Clinical Guide to the Diagnosis, Treatment, and Prevention
of Venereal Diseases. By S. Exgelsted, M.D., Physician-in-chief to the
City Hospital and Clinical Teacher at the University of Copenhagen. 8vo.
pp.489. Copenhagen (Denmark) : Reitzel, 1877.
The author of this treatise was one of the delegates sent by the Medical So-
ciety of Copenhagen to the International Medical Congress held at Philadelphia
in 1876, and he has paid us the compliment to dedicate the present work to his
"friends in America."
Dr. Engelsted has, with short interruptions, been attached to the City Hos-
pital of Copenhagen for nearly thirty years, and has for the last fifteen years
been sole physician-in-chief to the service for syphilis and skin diseases in that
large institution. He formerly published several minor works, such as On Con-
stitutional Syphilis, On the Means of Checking the Spread of Venereal Diseases,
Clinical Studies on Diseases of the Skin and Venereal Diseases, which have
been translated into German. In the present work he has united the expe-
rience gained by an extensive public and private practice during many years and
under cirumstances highly favourable to exact observation. We regret that it
is written in a language that is understood by so very few among the profession
in this country, and hope that the day may come when we may refer our readers
to an English translation ; for we do not doubt that, although our own literature
has produced prominent works on the same subject, they would be pleased by
reading it, and would often return to it for advice. It is quite an original work,
and a highly practical one. Throughout the book the author tells very little
1878.] Ex&elsted, A Clinical Guide to Venereal Diseases. 229
about what he has read, but states what he has seen. There is very little theory
in it, and while he does not advance any new theory himself, he does not adhere
blindly to any of those of his predecessors. Thus, after having briefly stated the
two doctrines about unity and duality, he says : —
" Both doctrines are in array ; both parties declare that there can be no doubt
about which doctrine is the right one. Having been warned by the theoretical
discussion in regard to the difficulties that may meet us, we had better, in prac-
tice, consider every local lesion after possible contact with syphilis, that is to
say after impure coitus, as being possibly the initial symptom of that disease.
Daily experience shows us that syphilis does not always begin with an induration,
but may be introduced by a soft ulcer or a seemingly inconsiderable fissure.
However readily, from a clinical standpoint, we may embrace the dualistic doc-
trine, we ought never to go so far as to say about a venereal ulcer (soft chancre,
or chancroid) that it cannot be followed by syphilitic symptoms, for by so doing
we shall sometimes be mistaken, and give our patients unreliable advice. On
the other hand, one is forced to admit that the venereal ulcer in its total aspect
and development has characters so well marked, that it is not only justifiable
but wise to separate it as a distinct form of disease in the clinical description.
This view is strongly corroborated by the consideration of the phagedenic (ser-
piginous) form of this ulcer, which, during three, four, seven years, or still
longer, may retain the same character and the same inoculability on the same
individual and on others ; which constitutes a local lesion, increasing by auto-
inoculation, not influenced either by mercury or by iodide of potash, but certainly
curable by energetic local treatment ; which, when once healed, does not break
up again, and which, at least as far as my experience goes, never occasions con-
stitutional syphilis."
The practical sense of the author influences even his nomenclature. He says
that the term condyloma, much used by English and German writers, has given
rise to great confusion, and advises, therefore, to give it up altogether, and only
use the two unequivocal terms vegetations for the acuminate, non-syphilitic
growths especially found with balanoposthitis and gonorrhoea, and mucous papules
(mucous patches) for the so-called large condylomata which constitute a syphi-
litic eruption.
He gives complete statistics of the 18,322 cases of venereal diseases he has
treated in the new City Hospital from 1864 to 1876. 3463 had venereal ulcer
(chancroid), 7424 syphilis, and 7435 gonorrhoea. In the course of the work he
generally confines himself, for statistical purposes, to one thousand of every affec-
tion, such as syphilis, gonorrhoea, and epididymitis.
On the skin of persons suffering from syphilis are often found large bluish or
lead-coloured spots. They seem to be a little depressed, do not vanish on pres-
sure, and resemble completely what English pathologists have called the mulberry
rash, and regarded as characteristic of typhus fever. They are most frequently
situated on the thighs, the loins, and the lower part of the abdomen. But these
lead-coloured patches have also been observed in individuals who were only af-
fected with gonorrhoea, or who had no venereal affection at all. As the author
has never found them without finding morpions (pediculi pubis) on the same
individual, he thinks that they are only due to the presence of these animals.
When the parasites are destroyed by shaving or other means, the rash disappears
gradually.
The appearance of mucous patches is much influenced by acrid secretions and
want of cleanliness. They are therefore more frequent in women than in men,
and again much more frequent in those who are not under public supervision.
He has found them nine thnes more frequent in this class than in those who are
under such control. As second (repeated) eruption, mucous patches at the anus and
genitals are found more than six times as frequently in women who are not under
230
Bibliographical Notices.
public supervision as in those who are subject to regular examinations. In the
mouth, on the contrary, they are found more than six times as frequently in those
under public supervision. The cause of this difference is probably that smoking
is more common among prostitutes than among the other class (servant girls,
seamstresses, etc.), whilst, on the other hand, the former are obliged to observe
more personal cleanliness.
White spots in the mouth (scaly patches, thickening of the epithelium) are
sometimes found in persons who are not infected with syphilis.
The chapter on General Paralysis is very interesting. The author does not
give his own opinion, but relates the results of a pupil of his, Dr. Jespersen, who
found syphilis in the history of 77 per cent, of 123 cases of paralysis treated in
the Lunatic Asylum of the city of Copenhagen, although attention had not been
called to the relation between the tAvo diseases when the histories were written.
Jespersen examined himself 34 patients, and proved syphilis in 33, and the
thirty-fourth had had ulcers on the genitals. 92 of the 123 had ideas of grandeur.
The intellect is always weakened. Spells of mania are common, but always short.
Kleptomania was found in eight. The paralysis is general, progressive, and
incomplete. Not a single case was cured. On an average the patients died ten
months after their admission into the hospital. Some of them lived five years.
The author maintains the difference between tertiary syphilis and scrofula.
The first is influenced by iodide of potash and in part by mercury, the second
not. Patients with tertiary syphilis are almost never re-infected, so as to present
induration, mucous patches, etc., whilst recent syphilis is found very frequently
in patients with marked scrofulous symptoms.
The chapter on inherited syphilis, comprising thirty pages, is full of interest.
Syphilitic women often bear many children, but the vitality of the offspring is
very small. Abortions are frequent (117 in 256 pregnant women with syphilis),
especially in the seventh month (39) and in the third (30). Out of 128 children
of syphilitic mothers, 58 were still-born, and 53 died within a year. The author
warns us against those who, prejudiced by theories, pretend that inherited
syphilis is not contagious. "In lying-in asylums, in hospitals, as well as in
private practice, every day brings new evidence that children of syphilitic
mothers may be born with undoubted symptoms of syphilis, and evidence is
not wanting that syphilis may be communicated from these children, in whom
it is congenital, to other individuals." The stage of the mother's disease
has much influence on the child. He has seen no small number of women
with considerable tertiary symptoms on the skin, the mucous membranes, and
in the bones, give birth to healthy children, wdio have continued healthy
afterwards. Women who have symptoms of secondary syphilis at the time of
their confinement, almost inevitably give birth to children who have or will
show symptoms of syphilis, even if their mothers have first acquired syphilis
during pregnancy. Exceptions from this rule are rare. Women with latent
syphilis often bear syphilitic children one after another for an indefinite time
until tertiary symptoms appear, when the prognosis for the child is much
better. Sometimes women with latent syphilis give alternately birth to syphilitic
and to non-syphilitic children, wdiich is a corroboration of Yirchow's theory,
according to which the blood is not permanently infected, but the virus is
deposited in deep organs, from which, from time to time, it is again brought into
circulation. It is very doubtful if the foetus can be infected from the father,
without the mother being first infected. The symptoms of syphilis that later
appear in the apparently healthy mother are, as a rule, characteristic of later
eruptions, such as grouped papules, deep ulcerations, and the like. This seems
to indicate that the mother has been syphilitic for some time, and that the earlier
1878.] Engelsted, A Clinical Guide to Venereal Diseases. 231
affections have been overlooked or have been latent. This view is also corrobo-
rated by the experience of every day, which shows that a mother who has given
birth to a syphilitic child is not infected by nursing it, even if she has no symp-
toms of syphilis, and is not known to have had any; whilst another woman
without syphilis, as a rule, will not escape infection by nursing it. If men marry
whilst they present symptoms of syphilis, the result is generally that they infect
their wives and beget syphilitic children. The same happens often if they marry
a short time after the disappearance of manifest symptoms. On the other hand,
syphilis is rarely communicated to the wife or to the children if the husband has
been entirely free from symptoms say for two years. This experience corrobo-
rates the view that the husband's role in regard to inherited syphilis is merely to
infect the wife ; whilst she, by localizations in the womb, or in other unknown
ways, may continue to be the cause of infection in the children. The symptoms
of inherited syphilis may be found at birth, but they appear commonly between
the second and the twelfth week. They have always the character of later
eruptions. Generally the efflorescences are grouped (secondary forms), but
gummatous growths (tertiary forms) may be found even a few weeks after birth.
Syphilis appeared in almost one-half of the cases within the first month, in three-
quarters within the end of the second, and in nine-tenths within the end of the
third month.
Mucous patches are a very important diagnostic sign. They are never well
developed in inherited syphilis, whilst they are one of the most common signs
of acquired syphilis in children. Likewise the lymphatic glands are generally
not swollen in inherited syphilis, whilst in children with acquired syphilis the
swelling is commonly very marked. Children who are born with syphilis die
generally within a week; of those in whom it appears several weeks after birth,
some are cured. Of 243 treated in the hospital, 137 or 56.4 per cent. died.
Acquired syphilis in children almost never causes death. So-called tar dim
syphilis, tertiary symptoms appearing at the second dentition or at puberty, is
probably a new eruption in individuals who have had inherited syphilis in
infancy.
Against the antimercurialists, who pretend that destructive forms are due
either to the combined mercurial and syphilitic dyscrasia, or to syphilis in a body
ruined by syphilis, the author contends that the icorst syphilitic affections may
be found in individuals who have never taken mercury. Of 7424 individuals
with constitutional syphilis treated from 1864 to 1876 in the hospital, 493 had
grave and destructive symptoms without having undergone any mercurial treat-
ment. As the destructive symptoms generally first appear later, he has separated
those suffering from repeated eruptions, of which there were 1561. Of these 263
or 16.7 per cent, had grave affections without having taken mercury.
In gonorrhoea he advocates injections. He thinks that it prevents the forma-
tion of stricture, since the latter affection seems to be much rarer now, when the
physician tries to shorten the course of the inflammation as much as possible by
injections than formerly, when, in compliance with the doctrine of the humoral
pathology, he was afraid to stop the gonorrhoea. He denies that it gives rise to
epididymitis, which occurs rarely under the use of injections, and which, when it
appears, is not at all rendered worse by continuing them. He denies also that
they give cystitis unless an uncommonly large syringe be used, or several small
ones in succession. If the discharge is purulent, he uses at once an injection of
nitrate of silver (ten grains to the ounce). After that the patient injects, four
times a day, sulphate of zinc (a scruple to eight ounces).
The last chapter treats of the means of preventing the spread of venereal dis
eases. In this are found all the regulations and laws concerning the subject in
Denmark. Most important of all measures are regular examinations of prostitutes
232
Bibliographical Notices.
[Jan.
They are practised twice a week in Copenhagen. The immense benefit derived
for the public from them is shown statistically by comparing the result of the
examinations in those who are under regular control, and in other women who
are not under control, but are occasionally arrested by the police on suspicion ot
prostitution. In the latter class venereal affections were found more than ten
times as frequently as in the former. As Dr. Engelsted read this last chapter
before the International Medical Congress at Philadelphia, it may be found in the
recently- published transactions of that body. H. J. G.
Art. XXX. — Cyclopedia of the Practice of Medicine. Edited by Dr. H.
Vox Ziemssex, Professor of Clinical Medicine in Munich, Havana. Vol.
XVI. Diseases of the Locomotive Apparatus, and General Anomalies oj
Nutrition. By Prof. H. Senator, of Berlin ; Prof. E. Seitz, of Giessen ;
Prof. H. Immermaxx, of Basel; and Dr. Birch-Hirschfeld, of Dresden.
Albert H. Buck, M.I)., of New York, editor of American edition. 8vo.
pp. xii. 1060. New York : William Wood & Co., 187 7.
The appearance of a sixteenth volume of this important work shows that the
editor has been obliged to abandon the intention, announced in the prospectus,
of issuing it in fifteen volumes, it having already outgrown the proportions origi-
nally marked out for it Xo doubt this change has been rendered necessary by
the diffuseness of some of the gentlemen who have been engaged to write. the
various articles for it, some of which are certainly treated of at greater length
than their importance would seem to demand. For instance in the present
volume, Immermann devotes over 180 pages to the discussion of corpulence,
a condition troublesome enough, it is true, if it be excessive, but one for which
the physician is rarely called upon to prescribe. His articles on Anaemia and
Chlorosis are also long, together occupying 320 pages. On the other hand,
Senator's articles on the Diseases of the Locomotive Apparatus, which seem to
us sufficiently full and elaborate, and which include descriptions of the different
varieties of rheumatism, gout, rheumatoid arthritis, rickets, and malacosteon or
mollities ossium, do not take up much more space than that, which, as we have
already said, is assigned to corpulence.
Senator in his article on Acute Rheumatism, when speaking of the pathogeny
of the disease, alludes to a theory with which many of our readers are probably
unacquainted. It appears to have been originally advanced by Pfeufer, but has
been especially advocated by Hueter. In the opinion of these gentlemen, endo-
carditis so far from being a complication of rheumatism, is really to be regarded
as the cause of the joint affection, which they believe results from embolism by
particles of extreme minuteness washed off from the endocardium of the left
ventricle. They contend that endocarditis may be present without giving rise
either to subjective or objective symptoms, and that, therefore, it maybe assumed
to exist even in those cases of rheumatism which appear to run their course
without cardiac complication. Even if we were to grant that endocarditis may
exist without giving indications of its presence, and that it not only occurs in
every case, but precedes the joint affection, it is impossible to understand why
these minute emboli should be impacted only in the vessels of the synovial mem-
branes, and never, or hardly ever, in those organs which are primarily, and most
frequently exposed to the chances of embolism in other forms of endocarditis, viz.,
the spleen, kidneys, brain, retina, bowel, etc. But unless we are to attach less
1878.J
Cyclopaedia of the Practice of Medicine.
233
importance to the physical signs of disease than we have hitherto done, it is in-
conceivable that in a disease like rheumatism, in which the precordial region is
constantly examined, endocarditis can often run its course without being detected.
The theory, therefore, seems to us to haye been built upon a very slight founda-
tion, and not to explain the phenomena of rheumatism any more satisfactorily
than a similar theory does those of chorea.
The author believes that the chilling of the surface which generally precedes
an attack, acts as an irritant upon a variable number of peripheral expansions
of centripetal nerve-fibres, through which the irritation is conveyed to the vaso-
motor and trophic nerve-centres, exciting them to abnormal activity. This
hypothesis, he says, agrees with the shifting character of the disorder, and the
possibility of an irritation in the central organs of the nervous system being
suddenly propagated to the central origin of nerves supplying the more diverse
tracts, is supported by analogy. In other words, rheumatism may have a spinal
origin, a theory which was foreshadowed in the pages of this Journal as long ago
as 1831 (see vol. viii. and xii.), by the late Professor J. K. Mitchell. This theory,
however, makes no attempt to define the nature of the irritation set up by chill,
and the author endeavours to supply this deficiency by supposing that it consists
in the abnormal development of an acid. During exercise, he says, a formation
of acids and acid-salts, of lactic acid and acid potassium phosphates, takes place,
and it is to the accumulation of these products that muscular fatigue is due.
Under ordinary circumstances, . these products are eliminated, but should the
cutaneous surface be chilled, their elimination will be checked, and they will
necessarily accumulate in the system until they can be otherwise excreted or de-
composed. The chill, he says, generally acts injuriously on the body when it is
heated and tired by exertion, and hence the joints are especially prone to become
the seat of the disease, because, next to the muscles that move them, they are
the most functionally active parts. The author attaches very little importance
to the fact that injections of lactic acids have given only negative results, because
the animals chosen for these experiments, such as cats, dogs, and rabbits, are
either wholly insusceptible, or very little susceptible to the disease. Moreover,
true perspiration cannot take place in these animals, for they are destitute of
sweat glands. Experiments of this sort could only have been expected to suc-
ceed if they had been conducted on animals such as the horse, which are natu-
rally liable to rheumatism, and which resemble the human subject in perspiring.
Holding these views in regard to the nature of rheumatism, it is not surprising
that the author should place more reliance upon the alkaline than upon any other
plan of treatment. The alkalies are to be given in large quantities until the
urine has become alkaline, and the violence of the disease has been checked. He
prefers the sodic salts to those of potassium, ammonium, and magnesia, and con-
demns the practice of wrapping the inflamed joints in cotton- wool, which, he says,
tends to aggravate the feeling of heat and other inflammatory symptoms, and
recommends in its stead the application of ice-bags, holding that the fear of
causing disease of internal organs by vigorous attempts to reduce the local inflam-
mation, is without foundation. This fear may be exaggerated, but our own
experience leads us to believe that patients derive no harm, and frequently a good
deal of comfort from enveloping the joints in wool or cotton.
Among the remedies for the relief of pain, he mentions one which we do not
recollect ever to have seen recommended elsewhere. Injections of carbolic acid
(one Pravaz syringe filled with a one per cent, watery solution), under the skin
covering the affected joints, are, he says, at once convenient and safe. A less
decided effect is produced by painting the joint with carbolic acid (one part of
the acid in fifteen of linseed oil) .
234
Bibliographical Notices.
[Jan.
In a note at the end of the volume, Dr. Senator's translator, Dr. E. Buchanan
Baxter, calls attention to the merits of salicylic acid with its salts and salicin, the
active principle of willow bark. The latter substance, when acted upon by fer-
ments, such as ptyalin or emulsin, splits up into saligenin and glucose, saligenin
being readily oxydizable into salicylic acid. Senator, to show that this change
takes place in the human body, relates the following experiment : He swallowed
thirty grains of salicin in powder ; in from fifteen to twenty minutes later his
urine gave a violet reaction with ferric chloride, showing that it already contained
salicylic or salicyluric acid. The action of salicylic acid and that of salicin in
rheumatism may therefore be assumed to be the same. As the importance of
these remedies in the treatment of rheumatism has already been frequently
alluded to in the pages of this Journal, it is only necessary to add that Senator
has recently recommended that they should be given conjointly.
Senator explains the presence of uric acid in the blood, in gout, in the following
way : " There is," he says, "much reason to believe that the spleen is, if not the
only, yet a very important source of uric acid. We see this in splenic leukaemia,
and in other instances brought forward by H. Rankc. The spleen, as a whole,
and especially its constituent follicles, are liable to enlargement of a physiological
kind also, viz., some hours after food, at a time when the products of gastro-
intestinal digestion are being absorbed. We find a corresponding increase in the
amount of uric acid eliminated several hours after a meal. An abundant meal
thus operates in a twofold manner to increase the production of uric acid : on the
one hand, by furnishing the system with more materials for its formation ; on the
other, by exerting a specific influence on the functional activity of the spleen.
He believes, however, that in addition to an increased formation of uric acid in
gout, the blood has also become less capable of dissolving it, in consequence of
an increase in the proportion of acid and of acid salts. Senator is also the writer
of the articles on Diabetes Mellitus and Diabetes Insipidus.
The remaining papers in the volume, with the exception of those on " Slight
Disorders caused by Catching Cold," and 11 Scrofulosis and Affections of the
Lymphatic Glands in general," which are respectively by Prof. Seitz and Birch-
Hirschfeld, are contributed by Immermann, who has written on anaemia, chloro-
sis, progressive pernicious anaemia, and corpulence. In his paper on the first of
these diseases, Immermann, in describing anaemic murmurs, says, that besides
being always systolic in rhythm, they correspond as regards their point of maxi-
mum intensity, precisely to those murmurs which are due to insufficiency of the
auriculo-ventricular valves. This statement is so utterly at variance with the
teachings of Walshe, Flint, and other authorities in physical diagnosis, that we
should have supposed it to be a typographical error, as it is unsupported by argu-
ment, were.it not that he gives, a little further on, the following explanation of
the production of anaemic murmurs : Owing, he says, to the altered state of
the blood, the muscular tissue of the heart is easily fatigued, and this liability to
premature fatigue extends to the papillary muscles connected with the auriculo-
ventricular valves. After any undue exertion on the part of the cardiac muscle,
a temporary paresis of the musculi papillares ensues. In consequence of this
the valve-flaps intrude into the auricles with every ventricular contraction; i. e.,
a transient functional insufficiency of the mitral and tricuspid valves is established,
and gives rise to a systolic murmur in the corresponding orifices. It is possible
that Walshe' s assertion that the anaemic murmur is audible only in exceptional
cases below the nipple, and that it is never perceptible as far as the left apex, is
too exclusive, since other observers state that it is occasionally heard over the
body of the heart. Our own experience leads us to believe that the anaemic mur-
mur is most frequently heard to the left of the sternum, over the upper part of the
1878.]
Cyclopaedia of the Practice of Medicine.
235
body of the heart, and that although invariably more intense towards the base of the
heart, it may sometimes be heard at the apex. In a case recently under our care, a
loud systolic murmur was perceptible at the apex as well as at the base, as long as
the symptoms of anaemia were present, but ceased to be audible when these had
yielded to treatment. When speaking of the auscultation of the veins, the author
cautions us against a source of fallacy which he says consists in the forced rota-
tion of the head to the opposite side, since the jugular vein is then compressed,
about its middle, by the tense cervical fascia and the belly of the omo-hyoid.
Now it is rather singular that Barth and Roger insist, in their Manual of Auscul-
tation and Percussion, upon the necessity of this rotation of the head in many
cases, in order to bring out the murmur, and that Prof. Flint lays great stress
also upon its importance.
The article on Progressive Pernicious Anaemia, although full in other respects,
does not contain any reference to the fact that this disease was fully recognized
and described by Dr. Thomas Addison, in his paper on the Constitutional and
Local Effects of Disease of the Supra-renal Capsules, under the name of Idio-
pathic Ana?mia, and that it was subsequently described in the Guy'' s Hospital
Reports (3d series, vols. hi. and v.), by Dr. Samuel Wilks, who at first gave to
it the name of idiopathic fatty degeneration, but subsequently adopted that sug-
gested for it by Dr. Addison.
As we have already said, the physician is not often called upon to treat corpu-
lence, and yet it is a condition which is occasionally the cause of great discomfort
to those who are afflicted with it, and its presence in a high degree not only modi-
fies the treatment, but unfavourably affects the prognosis of man}- diseases. It is,
therefore, a subject not Avithout interest for the practitioners of medicine, who
will find in Immermann's article much valuable information. Cases having fallen
under our observation in which an attempt to reduce corpulence by the use of
a restricted diet, or, in other words, by the so-called Banting method, has been
followed by impairment of health, we naturally turned to see whether or not Im-
mermann approved of this treatment, and found the following : —
" Quite in harmony," he says, "with what we have just said, is what has been
observed in a great many cases, in which, in order to guard against corpulence,
the consumption of fats, hydrocarbons, etc., has been reduced to a minimum, and
the body nourished almost exclusively upon albumen. Here, sooner or later, a
loss of the normal feeling of strength, a very uncomfortable and tormenting sen-
sation of languor and weakness has supervened, and, for good or evil, compelled
a discontinuance of the prophylactic treatment. A second danger, and one scarcely
less worthy of attention, depends on the incapacity of the digestive organs con-
tinuously to digest a sufficient quantity of albumen to meet all organic require-
ments."
The author also thinks that a diet consisting solely of albuminous articles, by
its tendency to the production of an increased amount of uric acid, may lead to
the occurrence of attacks of gout. He therefore concludes that —
' ' Even with a well-marked case of corpulence, the supply of glutens, hydro-
carbons, and even fats, must never be so curtailed as to produce a considerable
diminution of the natural feeling of strength and of the functional capacity of the
body, and further, the supply of albumen must never be so great that disorders of
digestion or signs of the lithic acid diathesis are produced."
The volume is, we think, well worthy to take its place alongside of its fellows
of this valuable series. J. H. H.
236
Bibliographical Notices.
[Jan.
Art. XXXI. — Hie loner Lectures Instituted to Encourage the Discovery of
New Truths for the Advancement of Medicine. Lecture V. On the Surgical
Complications and Sequels of the Continued Fevers. By William W. Khex.
M.D., of Philadelphia. Delivered February 1 7, 18 76. Washington: Smith-
sonian Institution. April, 187 7.
That typhoid fever is sometimes followed by affections of external parte, espe-
cially of bones and joints, has long been known, and is a fact familiar to all. But
that the continued fevers (typhus and typhoid) have so many and grave surgical
complications and sequelae as are treated of in this lecture, will certainly be a
matter of surprise to the majority of readers. Dr. Keen, omitting all reference to
erysipelas, venous thrombosis, hemorrhages, bed-sores, abscesses, and affections
of the eye, has considered at length "diseases of the joints, the bones, and the
larynx, gangrene, ha?matomata, and parotitis."
Of the joint inflammations that involving only a single articulation is rightly
declared the form that will most interest us. Not often met witli ; in a large
proportion of cases located in the hip ; generally terminating; favourably ; occa-
sionally causing anchylosis ; it not seldom produces spontaneous dislocation,
generally noticed after the third week, easily reduced when detected early, and
always to be watched for, especially in children. Effusion existing, "the position
of the leg becomes of the greatest possible importance :" and the limb should be
"kept in abduction and external rotation." It maybe mentioned in this connec-
tion that I have now under observation a case of this post-typhoid monarticular
inflammation in a child nine years old, in which it is the first phalangeal articula-
tion of the left middle finger that is affected.
For the bone-inflammation two causes are assigned: "first, thrombosis, or in
some cases possibly embolism ; and secondly, absolute inanition or want of nutri-
tion." " Scarcely any region of the body escapes ;" the disease appears some-
times early, sometimes late ; and "wide-spread mischief may follow in the osse-
ous system, when put to the test by labour, months and even years after such a
fever."
Of diseases of the larynx 169 cases have been collected, "of which at least G7
(and possibly many more) certainly involved the cartilages themselves." "Pa-
thologically, the troubles may be grouped into three varieties, viz. : 1. (Edema-
tous laryngitis. 2. Ulcerative laryngitis. 3. Laryngeal perichondritis." These
diseases "are exceedingly rare in children ;" occur in men three and a half times as
frequently as in women ; and are developed generally ' ' in the later fever, or more
frequently in distinct convalescence." That the prognosis is grave is shown by the
fact that of " 146 cases of all kinds of stenosis in which the result is recorded. 101
died," i. e., over 69 per cent. ; and of 56 cases in which there was cartilage-necrosis,
54 terminated fatally. "The seat of the necrosis in the majority of the cases is the
cricoid, next the arytenoid cartilages." "The earliest symptom of grave laryn-
geal disease is usually an altered voice," the hoarseness being soon followed by
dyspnoea. " Pain and tenderness, though often masked by the mental condition,
are generally present, especially in perichondritis ; . . . . dysphagia is especially
present in cricoid and arytenoid necrosis ; . . . . rarely is there any external
swelling." Treatment, and particularly operative treatment, is shown by statis-
tics to have a decided influence in lessening the great mortality attending these,
laryngeal affections ; markedly so when perichondritis is established, as under
such circumstances "death is almost unavoidable if no operation be done."
" Unless necessary, it is best not to operate during a paroxysm." Sometimes the
canula can be removed early, but in a large proportion of cases the laryngeal ob-
1878.) Keen, Complications and Sequels of Continued Fevers. 237
struction is permanent, and the tube consequently cannot, with safety, be dis-
pensed with. In the only case of this laryngeal affection that has come under our
care, in which we made tracheotomy because of oedema, the man, during the subse-
quent two years that he lived, was never able to be without the tube for more
than a few minutes at a time, the stenoses of the larynx being almost complete.
Of the two classes of cases of gangrene, those dependent upon pressure and
those arising spontaneously, special attention is called to the latter. Ordinarily
infrequent, they are occasionally met with in large numbers, as by Estlander, in
Finland, in 1865-7. "As far as the pathology of the cases is concerned, they
may be divided into two classes : 1, those with a discoverable clot ; and, 2, those
without such a clot."
The cause of the clots, it is held, is not the condition of the bloodvessels, but
is threefold: "1, the altered blood; 2, the weakened heart; and, 3, the
mechanical difficulties in carrying on the circulation, especially in distant
parts." Even in the cases in which no clots of any considerable size can be
found, the author believes that coagulation is still the cause of the gangrene,
which " begins as a blood-stasis in the capillary circulation." " The results vary
much according to situation and extent. In the extremities, if life be saved, the
result is usually an amputation, either by nature or by the surgeon."
The blood extravasations following typhoid fever, and consequent upon rup-
ture of muscles that have become extremely fragile, may be either ecchymoses,
diffuse infiltrations, or distinct hamiatomata ; these latter being particularly likely
to be found, "in the recti abdominis and the adductors of the thigh." The
size of the tumours " varies from that of a bean to that of an orange." Their
symptoms are often very slight, but if suspected to exist they may usually be
detected without great difficulty. They should be treated by incision, or, per-
haps as suggested, by aspiration.
Parotitis is declared to be "occasionally an exceedingly important surgical
complication, whose onset is always to be dreaded, lest it bring in other evils
worse than itself ;" among which evils are sloughing of the gland, venous throm-
bosis, necrosis, septicemia, facial paralysis and deformity, and anchylosis of the
jaw. The mortality of cases presenting this complication is shown to be much
above the average, being over 30 per cent.
As the result of his investigations Dr. Keen, in conclusion, points out that
typhoid is much more likely than typhus to be followed by surgical complications
and sequela? ; that these latter are most common in the earlier years of maturity ;
are much more frequent in men than in women ; are especially located upon the
lower half of the body ; are in general to be recognized without much difficulty ;
and are largely due to mechanical causes " working in conjunction with the pro-
foundly vitiated blood." " Their prognosis is naturally unfavourable yet not to
the extent we would suppose from the addition or sequence of such serious disease ;"
and their " treatment must be bold but not rash, conservative but not timid."
Appended to the lecture is a very extensive bibliography, for assistance in the
preparation of which indebtedness to Drs. Toner and Billings is expressed. It is
certainly a matter of great gratification to all the profession of our country that
there are now in Washington very complete libraries to which ready access can
be had, and which can with little difficulty be drawn upon at any time.
This brief glance at some of the more salient points of Dr. Keen's lecture can-
not be closed without an expression of the pleasure had in its perusal. If it does
not report "the discovery of new truths for the advancement of science," it does,
what is of perhaps equal importance, viz., call attention to the nature and gravity
of diseases that have been met Avith, but the notices of which are scattered here
and there through a large number of books and journals, and consequently diffi-
cult to be found and likely to be overlooked. P. S. C.
238
Bibliographical Notices.
[Jan.
Art. XXXII. — Tlie Cure of Rupture, Reducible and Irreducible, also of
Varicocele and Hydrocele, by new methods. By George Heaton. M.D.
Arranged by J. H. Davenport, M.D. 12mo. pp. 196. Boston: H. O.
Houghton & Co., 1877.
This little volume contains 196 pages of instructive matter. It advocates a
simple method of treating every variety of rupture. It maintains that a radical
cure can be accomplished by strengthening the fibrous tissues, " which are nature's
chief bulwark against hernia."
A "method of tendinous irritation" is carried out by injecting about ten minims
of the fluid extract of quereus alba into the fibrous borders of the rings and canal
through which the hernia protrudes, with an instrument similar to the hypodermic
syringe. By thus irritating the part, plastic lymph is deposited iu and around the
tissue, and thus a wall is made and remains, which prevents the hernia.
After the operation, dull pain about the part is felt for several hours, and some
tenderness exists for several days. A pad and bandage are applied immediately
after the operation, and worn for two months or more. The sac, as Avell as its
contents, are to be returned, if possible, into the abdomen before the injection is
made. The sac, when it cannot be returned, will be contracted by the effects
produced by the injection. By means of simple taxis, patiently persevered in,
Dr. Heaton has succeeded in reducing hernia? which had apparently been irre-
ducible for ten or twenty years or more. When the hernia cannot be reduced,
cutting into the sac and dissecting away the adhesion and returning the parts into
the abdomen is recommended, and considered as safe, trustworthy, and efficient,
and no more to be dreaded than any other surgical operation of moderate im-
portance.
The author very properly condemns the careless, not to say criminal, manner
in which some surgeons send a patient to have a truss applied by a surgical instru-
ment maker, whose acts in the case are entirely empirical.
The operation of Gerdy, Wiitzen, Wood, and others, consisting of invagination,
is now generally laid aside by surgeons, as not possessing the merit claimed
formerly, the invaginated material operating as a foreign body is often gotten rid
of by nature, thus allowing the recurrence of the hernia.
That the fibrous tissue around a hernial opening may be strengthened by the
deposit of coagulable lymph, is well shown by the fact that in cases of recent
hernia? which have been reduced at once, and the parts properly treated, no re-
currence of the hernia has taken place, though the patients have been subjected
afterwards to a greater strain than before the hernia took place. And again, in
cases of old hernia?, when from a sudden exciting cause, laceration of the margins
of the hernial opening has taken place, the parts have been closed effectually by
the deposit of coagulable lymph, and thus all protrusion prevented.
In the autumn of 1875, the writer of this review had such a case in the person
of an old gentleman 64 years of age, the subject of an old reducible inguinal
hernia for fifteen years. He jumped from a street railroad car which was in motion,
immediately he felt something give way under the pad of his truss. The pain
was considerable, and the neck of his hernial tumour, on removing the truss, was
much enlarged. The mass was returned, the parts supported by a bandage, and
rest maintained by opium was directed. He entirely recovered, and now wears no
truss. The parts, the fibrous tissues, were strengthened by the coagulable lymph
thrown out from the margin of the lacerated opening. Doctor Heaton' s treat-
ment is well worthy of being tried when a radical cure is endeavoured to be
attained.
1878.]
Mason, On Hare -lip and Cleft Palate.
239
In regard to the cure of hydrocele by the introduction of red precipitate, we
feel compelled to hesitate before recommending it. With the tincture of iodine
in this affection, unlike invagination for hernia, we have been uniformly successful
during an extensive experience with it. Red precipitate does and will salivate.
The book is handsomely gotten up, ancl is in every way a very readable one.
W. S. F.
Art. XXXIII.— On Hare-lip and Cleft Palate. By Francis Mason, F.R.
C.S., Surgeon and Lecturer on Anatomy at St. Thomas's Hospital, etc. With
sixty-six illustrations. 8vo. pp. viii. 134. London : J. & A. Churchill,
187*7.
Rarely indeed can any medical book be read with greater comfort than this.
Heavy paper, large type, wide margins, clear, illustrative, and numerous wood-
cuts, all combine to lighten the labour, while the very excellent character of the
matter arouses and keeps alive the interest for the hour or two its reading
demands. The two essays on kindred subjects appeared in St. Thomas's Hospital
Reports for 1875-6, and are appropriately dedicated in the present form to the
memory of the late Sir William Fergusson as the memento of a long friendship.
Not much that is really new will be found in the book, but as a resume^ of our
existing knowledge and as a record of the opinions of one whose practical experi-
ence lends weight to these opinions, it is a most excellent book. He who can
combine the suggestions of many minds as to any given topic and so formulate the
practical conclusions drawn from them as to interest and instruct always does a
good service to the cause of truth, and this service Mr. Mason may fairly claim as
his own.
He points out the fact that in most cases of hare-lip involving the jaw there is
an absence of one or both lateral incisors, i. e., the intermaxillary bone does not
then possess all four of the incisor teeth. He gives several instances of maternal
impressions which were alleged to be the cause of the deformity, but does not place
much reliance on the statement. Not only is it occasionally hereditary as in
Demarquay's instance of eleven cases in three generations, but, as Fergusson first
pointed out, a partial but similar defect is generally found in one or both of the
parents. Very properly and in accordance with almost all later teaching, he
advocates an early operation, and in those cases in which nutrition will be im-
paired by delay, the earliest practicable operation. Not only do they suck better,
but a wide cleft palate, if it exist, may be so narrowed that the edges in time may
almost touch. All the ingenious and singularly varied operations are then de-
tailed. In describing the ordinary operation he gives the excellent advice to
beware of removing too thin a piece from the margins of the fissure, since this
is a cause of the V-shaped dip so frequently left on the lip.
Although staphylorraphy was done in this country by Warren .as early as 1820,
and by a few others at an earlier date, yet the real success of the operation is a
matter of the last twenty years. Unless there be good reason for doing the ope-
ration earlier (not unfrequently both advisable and successful), he thinks that
generally it should not be undertaken before the age of five or six years, especially
on account of the thinness of the tissues. The use of nitric acid in some cases gives
good results, but he prefers in general the knife with subsequent division of the
palate muscles, in describing which procedure he gives due credit to Pancoast,
Mutter, and Warren. Warren's brilliant success in closing cleft of the hard palate
by uraniscoplasty, and Langenbeck's operation by muco-peri osteal flaps (an opera-
240
Bibliographical Notices.
[Jan.
tion really done eight years before, in 1852, by Mr. Avery), and DiefFenbaeh's
operation by osteoplasty with their various later modifications, are all minutely
and clearly described. The niuco-peri osteal flaps if they do not give a bony roof,
which is very doubtful, do give so firm a roof as to be practically as useful, and is
not followed by any exfoliation of bone as in osteoplasty. Hence as a rule he
gives this decidedly the preference. Where both the hard and the soft palate arc
involved he rather leans to a complete operation at once, though most authors
prefer to close only the hard palate at the first operation. To meet the emergen-
cies of nursing in cleft of the hard palate, he has devised an ingenious nipple with
an artificial roof attached to it. W. W. K.
Art. XXXIV. — Circular Orders No. 3, War Department, Surgeon-General' s
Office, August 20, 1877. Report on Lister's System of Wound Treatment.
By Assistant- Surgeon Alfred C. Gikakd, U. S. A. pp. 12.
While travelling in Germany and England, Dr. Girard used his opportunities
for professional observation to most excellent purpose, and has placed not only
the medical corps of the army, but the entire medical profession, under deep obli-
gations by this modest yet thoroughly useful report. Within twenty minutes'
reading he has given the most complete resume' of the application of the antiseptic
system of surgery that we are acquainted with. Were it possible, we should like
to see his brief pamphlet reprinted in our leading medical journals, and spread
broadcast throughout the profession, that no one might be without the opportunity
of testing its advantages.
His paper is divided into two parts : in the first he relates the manner in which
he was convinced of the advantages of the system ; and in the second he gives a
brief but complete description of the materials used, their mode of preparation
from the simple means readily found by every one, and the details of their appli-
cation. Somewhat of a sceptic at first by his relations with the opponents of the
system, he was forced into its support by seeing accumulating evidences of its
value in travelling from one Lister hospital to another ; some of them hospitals
used for centuries, and hot-beds of infection, in which nearly every case was sure
to be followed by grave accidents, and every method had failed, till the use of
Lister's method, with all its precautions, had banished them. Xussbaum, for
instance, who had lost even eighty per cent, of his patients from pyaemia, has
seen it absolutely disappear. No one has stated the possibilities of the method
more clearly, and we believe more truthfully, than the author in the following: —
"Who, before this, would have fearlessly opened the knee-joint for suppura-
tive arthritis, as I saw done under the spray, the patient recovering in a few days
with a sound joint '? Who would have expected an OA'ariotomy, with general
adhesions, in a woman of seventy-five, to heal in eight days without a symptom
of reaction, or a laparotomy for the liberation of incarcerated peritoneal hernia in
a moribund patient healing in six days, or a resection of the ulna in nine days ?
I observed several hip-joint resections recovering in the most favourable manner,
numbers of compound fractures of the extremities knitting under Lister's dress-
ing like simple ones ; even comminuted ones, which formerly would have induced
renewal of the limb, united without an unfavourable symptom. Cancers which
had been removed with great loss of substance united by first intention ; other
tumours were extirpated, and the operation caused no more inconvenience than
a simple incision. The smell of putrefaction was banished from wards where
scores of patients were lying with grave injuries and severe wounds."
Surely before what he well calls such "remarkable clinical results attained by
Lister and his followers,'' it is imperatively demanded that the system, which
1878.]
L o o m i s , Lectures on Fevers.
241
has been so supinely observed only in this country, should be actively and ener-
getically put to the crucial test of experience. We rejoice that Mr. Lister has
gone to London. He has accepted the gage of battle. If his method is worth-
less, he cannot fail to be attacked and vanquished ; but if it be a genuine and
important improvement, he will win a \Vaterloo.
Any one who wishes to test the system will find himself well informed as to
materials and methods by the second and larger part of the paper, and very pro-
perly the author insists on the necessity for attention to all the seemingly minute
and troublesome details, without which only failure may be expected.
W. W. K.
Art. XXXV. — Illustrations of Clinical Surgery. By Jonathan Hutchin-
son, F.R.C.S., etc. Fasciculus VII. Folio, pp. 143-172. Philadelphia:
Lindsay & Blakiston, 1877.
The attention of the readers of the Journal is again invited to the very hand-
some work of Mr. Hutchinson. Those who are not familiar with the work by
personal acquaintance have been made aware, from time to time in these pages,
of its value as a series of surgical portraits. The present fasciculus, No. VII.,
only contains two plates, illustrating acne in xanthelasmic positions, and true
xanthelasma palpebrarum.
This affection, first described as viteligoiclea plana, would seem to have some
connection with sick headache, it at least occupies those inner portions of the eye-
lids which are so commoiily the seat of pigmentation during an attack of headache
or biliousness, and is much more common in women than men. In a large pro-
portion of the cases observed and collected by Mr. Hutchinson, the sufferers from
this affection had been also sufferers from sick headaches. The yellow spots re-
sembling a bit of chamois leather let into the skin, make their appearance in
middle and advancing life, and beyond their unsightliness cause but little annoy-
ance. Treatment is of but little avail. This affection is complicated sometimes
with acne, sometimes with minute cysts, and in some cases the leather-like patches
are someAvhat elevated above the surface of the skin, while at others they are per-
fectly level with it.
Mr. Hutchinson gives a more generous amount of letter press in this fasciculus
than usual, and the contained table of seventy-four cases gives value to it. The
plates themselves are beautiful illustrations of chromo-lithography. While the
general surgeon will find this number less interesting than some of those which
have preceded it, he can hardly fail to agree with us that it forms a suggestive
part of a beautiful and valuable work — one which must add lustre to the name of
its author and prove of much service to the profession. S. A.
Art. XXXVI. — Lectures on Fevers. By Alfred L. Loomis, A.M., M.D.,
Professor of Pathology and Practical Medicine in the Medical Department of
the University of the City of ]STew York. 8vo. pp. xii., 403. Xew York :
William Wood & C o . , 1877.
These Lectures on Fevers, like those on Diseases of the Lungs, Heart, and
Kidneys, by the same author, which were published about two years ago, were
No. CXLIX Jan. 1878. 16
242
Bibliographical Notices.
[Jan.
delivered in the Medical Department of the University of the City of New York,
and constitute part of Dr. Loomis's regular course on the Practice of Medicine.
In the notice of the first series, which appeared in the July number of this Journal
for 1875, we expressed the opinion that it was not marked by any striking origi-
nality, and after a careful examination of the volume before us, we find it im-
possible to come to any other conclusion in regard to its contents. These lectures
are probably as good as those delivered in many of the leading colleges of the
United States, but they are certainly no better than some we have listened to,
whose authors have never yet thought it wise to publish them. We look in vain
throughout the book for new views of pathology, and for new methods of treat-
ment. As part of a course crowded into a few months, they would not specially
invite criticism, but the author has no right to complain if they are condemned as
elementary and commonplace, when he seeks to extend the influence of his teach-
ing by issuing them in book form.
The author divides fevers into three classes, as follow : 1st. Contagious ; 2d.
Malarial ; 3d. Miasmatic contagious. The first class includes typhus, relapsing,
scarlet, and miliary fevers, smallpox, and measles ; the second, the different
varieties of malarial fevers, together with dengue, and typho-malarial fever ; and
the third, typhoid and yellow fevers. The existence of miliary fever as a dis-
tinct disease has been denied by most good observers, but Dr. Loomis, although
he does not positively say that he has ever himself met with a case, thinks that it
is entitled to recognition. He therefore describes the symptoms which are usually
ascribed to this disease. If it really occurs as an epidemic, as he says it does, in
certain parts of Belgium, France, England, Germany, and Italy, attacking from
one-tenth to one-fifth of the Avhole population in the districts where it prevails,
it seems to us that it would have secured for itself an undisputed place in the list
of diseases.
Seven lectures out of the thirty are devoted to the consideration of typhoid
fever, which, the author says, although not strictly a contagious disease, never is
of spontaneous origin. In other words, he ranges himself with those who believe
that the emanations of sewers or privies will not produce typhoid fever unless
they are contaminated by the discharges of a person suffering from the disease.
In this opinion he is opposed to Murchison. who, in his work on Fevers, has ad-
duced many instances where the disease could be traced to no other cause than
defective drainage. This is, however, still an open question which we must wait
for further observation to settle.
The author gives only a qualified approval to the use of the cold bath in the
treatment of typhoid fever, saying that it should never be used after the second
week of the disease, and that, if you do not succeed in maintaining a low range
of temperature after four or five baths have been given, you will gain nothing
by pushing this plan of treatment further. We believe ourselves that the cold
pack or sponging with cold water, although unquestionably less efficacious in re-
ducing the temperature of the body, is, in many cases, a safer means of applying
cold, as it involves less disturbance of the patient. He regards quinia as a valua-
ble adjunct to the cold bath in the treatment of this disease, believing that if it is
given directly after the patient returns to his bed, it will generally delay the re-
curring rise of temperature. He recommends that as much as from thirty to
forty grains should be given in the course of two hours, a dose which he also oc-
casionally prescribes, it may be remembered, in pneumonia, and which, while it
undoubtedly often accomplishes the purpose for which it is given, will sometimes
provoke nausea and vomiting. During the third or fourth week of the disease,
if the temperature continues high, he is accustomed to add digitalis to the quinia.
as he has found it, when given in this combination, to possess decided antipyretic
1878.]
A Guide to Therapeutics and Materia Medica.
243
powers. The doses in which he prescribes it, from ten to twenty grains of the
powder daily, strike us as being unnecessarily large, and as its use in such quan-
tities is not unattended by danger, we are rather surprised that he has left his
recommendation unaccompanied with a caution.
Of the remaining lectures in the volume, two are devoted to yellow fever,
eight to malarial fevers, four to typhus fevers, one to relapsing fever, and the rest
to the exanthemata. J. H. H.
Art. XXXYII. — A Guide to Therapeutics and Materia Medica. By Robert
Farquharson, M.D. Edin., Lecturer on Materia Medica, at St. Mary's
Hospital Medical School. Enlarged and Adapted to the U.S. Pharmacopoeia,
by Frank Woodbury, M.D. Philadelphia : Henry C. Lea, 1877.
This book, designed, as stated in the preface, to supply the wants of the student
and junior practitioner, contains 410 duodecimo pages, and is an effort to present
in a compact form the leading facts of materia medica, experimental and practical
therapeutics, and toxicology ; the original English work, which would appear to
be little more than an outline of the physiological action of medicines together
with the therapeutical indications deducible therefrom, having been both altered,
so as to conform with the U. S. Pharmacopoeia, and greatly enlarged by the
editor.
The introductory chapter is devoted to a general, and in the main correct,
description of the methods of prescribing and administering drugs. There are,
however, several points to which exception maybe taken: for example, in the
paragraph on "Prescribing for Children" the statement is made that at the age
of Jive or six years dilute prussic acid may be given -in doses of THJ-iij, and that,
in a child of the same age, excellent results have followed the administration of
%j °f "tinct. ferri" ter die. The first dose is certainly excessive, and the case
must be rare in which the second could be given with safety ; again, in giving
the proportional doses for children, the dose at the age of five years is set clown
as "-2V=r !
The subject matter of the book is divided into three sections, and in the case of
the more important drugs, the text is divided into two parallel columns, contain-
ing their physiological and therapeutical actions, and the idea of drawing thera-
peutical indications directly from physiological action is a good one.
In the first section, entitled "Remarks on Certain Classes of Remedies," we
find that, with the exception of diuretics, emetics, expectorants, and purgatives,
the classes considered are of little importance, no mention whatever being made
of such prominent therapeutical groups as alteratives, anaestheties, astringents,
cardiac stimulants and sedatives, excito- and depresso-motors, mydriatics, and
tonics.
The second section, which forms the bulk of the volume, is given to the con-
sideration of the " Remedies comprised in the Primary List of the U. S. Phar-
macopoeia." The different medicines are for the most part enumerated alpha-
betically, an arrangement which is undoubtedly the best for works intended for
reference. The materia medica proper is restricted to an enumeration of the
officinal names of the drugs, with their preparations and doses, and with occasion-
ally a few words of description. W e regret to notice mistakes as to the strength
of some of the preparations, and that sufficient care in a few cases has not
been observed in stating doses : for instance, the dose of tr. benzoini comp.
when mentioned among the preparations of aloes is given as Tttx-xxx, when
244
Bibliographical Notices.
[Jan.
among those of benzoinum, f^j-ij ; the dose of tinctura humuli and of tinctura
lupulinse is f^ss-ij ; acidum carbolicura, which is described solely as a solid, is given
in doses of gtt. i-ij, and glyceritum acid, carbol. in doses of Hf^x-xl, equivalent
to double the quantity of carbolic acid advised.
The third section includes a number of drugs which, although in frequent use,
are either not officinal or belong to the secondary list U. S. P. The most import-
ant of these are acidum salicylicum, eucalyptus globulus, and jaborandi.
After the descriptions of many of the drags prescriptions are introduced to illus-
trate the art of prescribing, which are neither models of correct writing nor of
grammatical accuracy. The author has forgotten to always put the names of the
ingredients in the genitive case, and in many of the formulas we notice such
errors as magnesias sulphatis for magnesii sulphatis, ammonia? carbonatis for
ammonii carbonatis, spiritus ammonii aromat. for spiritus ammonia' aromat., etc
The book is printed in large, clear type, and has an unusually full index.
L. S.
Art. XXXVIII. — Hospitals: their History, Organization, and Construction.
Boylston Prize Essay of Harvard University for 187G. By W. Gill Wylie,
M.D. 8vo. pp. 240. New York : D. Appleton & Co., 187 7.
In this age of scientific scepticism, when those who are supposed to know most
about a subject are usually so provokingly cautious in their assertions with re-
gard to it, it is refreshing to meet with treatises which deal positively with, and
settle off hand and peremptorily those questions which experts seem by no means
so clear about. Such a work is that of Dr. Wylie, and if a few changes could be
made in the laws of chemistry and physics which relate to gases, and also in the
methods of production and reproduction of disease germs, it would be a most satis-
factory manual, so far as hospital construction is concerned. It is necessary, how-
ever, to warn readers that Providence has not yet arranged matters exactly ac-
cording to Dr. Wylie' s ideas, and until it does, at least one-half of his excessively
dogmatic statements have no scientific basis. It is evident that nothing should be
accepted on the "ipse dixit" of a writer who makes such assertions as the follow-
ing : "Air should not be allowed to stand still, especially in the dark. With the
light on it there will be motion, for light produces heat. . . . Air when
confined, in a very short time, from the germs that all air seems to contain to a
greater or less extent, will foul itself by the birth, life, death, and decomposition
of animalcules, and soon loses its vitalizing power" (p. 119). Again, on page 105,
we are told that "Malarial and noxious gases float near the ground, " and that
" Air confined in such (£. e. dark) chambers, becomes stagnant, and prolific of
myriads of low grades of life or living organisms, which, by decomposition, soon in-
fect it with poisonous matter." All of which is entirely incorrect. Light does not
produce heat, air when confined and motionless is purified, so far as living organ-
isms are concerned, because they slowly subside, and the idea that living organisms
develop in stagnant air alone, shows a remarkable ignorance of the elementary
principles of biology.
Again, on page 127, we are told that " Carbonic acid gas [in the breath], being of
a higher specific gravity than air, sinks to the floor." Such a statement might be
expected in a circular advocating a patent ventilator, but is melancholy reading in
a "Boylston Prize Essay." What possible respect can be had for opinions on
ventilation which are based on such a statement as this ?
Elsewhere, it is asserted that "In all long narrow chambers, the natural cur-
1878.]
Toland, Lectures on Practical Surgery.
245
rent of the inclosed air is in the direction of the long axis, being that of least
resistance." This is simple nonsense, for the direction of the current of air will
be from one opening to another, no matter where the openings are. Ground
air seems to give the author great apprehension, so much so, that he would put
layers of slate in the brick pillars, seven or eight feet high, on which the ward
is to rest, in order "to intercept the passage of ground air up through them,"
which again is absurd. Hot- water heating he considers more expensive than open
fires, whereas, the fact is precisely the reverse.
We have given specimens enough to prove the unscientific character of the work,
and in all that relates to construction, heating and ventilation, what is new is gene-
rally incorrect, but it will require a good knowledge of the subject to tell what is
new and what is not.
The historical part of the book is a fair compilation, which would have been
much improved by consulting Haeser, 1 and the interesting data collected by Yir-
chow, in relation to ladreries or leper hospitals. The statement that " the best
encyclopaedias, both English and American, make no reference to the fact that
hospitals were known previous to the coming of Christ," shows that Johnson's
new Cyclopaedia has not been seen, and the statement taken from Bernan (p. 19),
that Cardinal de Polignac wrote " Le Meeanique a Feu," is incorrect, since it was
written by M. Ganger, as Tomlinson has proved. The book is interesting, but
unscientific and illogical in a high degree, and forms an unfavourable contrast
with some of the other essavs to which have been awarded the Bovlston Prize.
J. S. B.
Art. XXXIX. — Lectures on Practical Surgery. By H. H. Toland, M.D.,
Prof, of Principles and Practice of Surgery and Clin. Surg, in Med. Dept.
of University of California. 8vo. pp. xii., 508. Philadelphia: Lindsay &
Blakiston, 1877.
We have read over two-thirds of this book, and must confess that the perusal
has not left its trace by a single new or valuable idea. The author, in his pre-
face, confesses that he could not find time to write a book, but would "talk"
one, and a stenographer accordingly "took down his oral lectures."
That Dr. Toland' s surgical pathology is scarcely what we ought to expect from
a modern professor of surgery, let the following quotations serve as samples :
"Pus is unquestionably a secretion. It is prepared [what a delicious indefinite-
ness lurks in the word!] by the capillary vessels" (p. 77). His 4th class of
semi-malignant tumours is " fibroplastic or encJwndromatous" (p. 122). Scrofula
' ' may be defined as a peculiar constitution, which, when fully developed, is
characterized by the formation of tubercle" (p. 141) ; and tubercle is defined
see-saw-wise as "scrofulous sarcoma" (p. 143). The occlusion of vessels by a
thrombus is thus described : "So soon as sufficient inflammation of the internal
coat can take place, plastic lymph is effused ; this becomes organized, and closes
the vessel permanently" (p. 154). " Exostosis means an unnatural growth of a
bone" (p. 317).
That his teaching is meagre to very surgical starvation is only too evident if
his lecture on any single subject in the whole book is read. Morbus coxarius,
for instance, occupies four and a half pages, two of which are given almost wholly
to two engravings (neither of which is described or even alluded to), and nearly
1 H. Haeser, Geschiehte Christlicher Krankenpflege, und Pflegerschaften, Berlin,
1857, 8vo. De Cura Aegrotorum, publica a Christianis oriunda, Gryphiswald, 1856, ito.
246
Bibliographical Notices.
[Jan.
a, page more to some cases. He also expresses the surprising opinion that "am-
putation of the hip is much better than resection." Xo mention is made of the
change in the gluteo-femoral fold, or of the peculiar posture ; the various stages
of the disease are not even named, and, apparently to fill out the hour, the last
six lines of the lecture (which began with incised wounds of the joints) discuss(?)
resection of the elbow, ankle, and wrist ! Five pages suffice for gunshot wounds ;
three and a half for "diseases of the spine." On the other hand, syphilis,
though inadequately treated (for example, no mention whatever is made of atro-
pia in syphilitic iritis !), occupies fifty pages, one-tenth of the book.
In his arrangement of topics, he seems to have followed no systematic plan,
but was apparently guided somewhat by the fact that sometimes a subject would
fill out the allotted time. Some illustrations have already been given, and the
"Table of Contents" suggests many more ; Lecture XXXI V., for instance, is a
melange of the nose, lupus, the ear, the jaws, the mouth, the tongue, the tonsils,
and the teeth ; and in Lecture XLII. we have an olla podrida of "skin grafting,
epithelioma, deformities of the nose, and bunions."
The sins of omission are no less glaring than those of commission. Pyaemia
and erysipelas are nowhere discussed ; antiseptic surgery is utterly ignored ; im-
movable apparatuses (except an allusion to the old starch bandage) are not
named in connection with fractures ; nor are Buck's extension apparatus, nor
X. R. Smith's, nor Hodgen's splints. Adams's subcutaneous section of the neck
of the femur and Esmarch's method meet with similar neglect ; we could there-
fore hardly expect any mention of the galvano-caustic apparatus or Pacquelin's
knife. Had the index itself also been omitted, scarcely any loss would have been
felt, for its two scanty pages are absolutely worthless.
The whole book, on almost every page, is filled with cases in which the promi-
nence of his patient, rather than the nature of the accident or the disease, semis
to be the reason for its introduction. Moreover, were we one of the Judges of
the Supreme Court of California, we should object to having embalmed in a book
(p. 365) the fact that we had transmitted to two- thirds of our children a hyper-
trophied nose. The egotism of the author is, however, still more painfully evi-
dent in many instances, and we should think would raise issues of personal judg-
ment and professional reputation on every hand, involving him in endless animosi-
ties. He narrates many cases in which other practitioners, sometimes mentioned
by name, had failed or differed from him, and in which he ostentatiously relates
how his own skill had triumphed over their blunders. "I can say to strangers
in this class [the regular members knew it, of course] that I have never in my life
made a mistake in the diagnosis of serous or purulent secretions" (p. 359). " I
have performed more operations for aneurism than any surgeon in America" (p.
170); the grammar of which sentence about equals its modesty. But when we reach
McClain's case, and read, "It was one of my triumphs, and was called Toland's
luck in surgery" (p. 306), we cease to criticize.
The book is handsomely printed ; the ideas are in general well expressed, and
the illustrations arc well done, though of no special value. With so many really
excellent and thorough text-books on surgery as we possess, we see no field for
this work, and fail to find in its character, or in the needs of the student or prac-
titioner, any justification for its publication. W. W. K.
187$.] Tanner, Index of Diseases and their Treatment. 247
Art. XL. — The Morphology of the Skull. By W. K. Parker, F.R.S.. Hun-
terian Prof, at Royal College of Surgeons, and G. T. Bettaxy. ALA., B.Sc,
etc. pp. 3G8. London: Macmillan & Co., 1877.
While so miicli has been said respecting the points of resemblance between
the medical profession in England and this country, little or nothing has been
remarked of the contrast. Scarcely a month passes -without a work being issued
from the English press concerning which expectations of author and publisher
cannot be materially aroused in contemplating its prospective sale in the American
market. Indeed, many such books cannot be published in America at all, except
as private speculations on the part of the authors.
English medical journals have published from time to time within the last
twenty years, series of elaborate and technical papers, on the anatomy of animals.
These papers are never copied in the American press, nor do any contributions
resembling them in kind ever appear therein. "We have few or no writers and
practitioners in this country of the type of Maclise, Humphry, and Callender. All
these facts point to the one conclusion, that the science of anatomy as understood
by many leading Englishmen, and as sympathized with by the body of the English
profession, has no place in the thought of the American physician. Indeed, the
student is continually warned against indulging in such sympathy, and recently a
brilliant Xew England professor informed his students that it1 they desired to
indulge in such they had best take down then- signs or never put them up.
The book before us. which has excited these reflections, is an abridgment of a
number of memoirs by W. K. Parker, who. we have been informed from private
sources, was at the time of their preparation actively engaged in the general
practice of medicine. This one fact is, perhaps, the most interesting one which
can be gleaned from the entire volume. Many who would care nothing for the
technical matter of the book, would recall this fact with interest. As long as
every man must have a "hobby" for his hours of • relaxation, no one need object
if it chances to take the direction of studies in the Morphology of the Skull.
The work is divided into nine chapters, arranged as follows : (1) Preliminary
Embryology. (2) The Skulls of the Dog-fish, and the Skate. (3) The Skull
of the Salmon. (-±) The Skull of the Axoloth. (5) The Skull of the Common
Frog. (6) The Skull of the Common Snake. (7) The Skull of the Common
Fowl. (8) The Skull of the Pig. (9) The General Morphology of the Skull.
The text is illustrated with eighty-six well-executed wood-cuts, and the whole
is expressly designed as an educational volume, for the convenience of students.
Summaries of nearly every stage and of each chapter from the second to the
eighth have been carefully drawn up. By the help of the index, the history of
individual bones or tracts can be examined comparatively. The authors are
enlisted in the ranks of advanced scientific workers, and close their volume with
an eloquent passage upon the value of morphology as an evidence of design in
nature. H. A.
Art. XLI. — An Index of Diseases and their Treatment. By Thomas Hawkes
Taxxer, aI.D.. F.L.S. Second Edition. Revised by W. H. Broadbext,
ALD., F.R.C.P., Phys. to the London Fever Hospital, etc. 8vo. pp. xxx..
432. Philadelphia: Lindsay & Blakiston. 1877.
This book is not intended for students, but for practitioners of medicine who
are, of course, familiar with the nature of disease and its symptoms, but who
248
Bibliographical Notices.
[Jan.
sometimes need to refresh their memory as to its treatment, when, as occasionally
happens, the remedies fail which they are accustomed to rely upon. The plan
of the book is simple. About two-thirds of it are devoted to a brief descrip-
tion of every disease to which flesh is heir, and a list of the remedies usually
employed in its treatment ; reference being frequently made to an appendix
containing upwards of four hundred prescriptions, all of which have proved useful
in the hands of competent observers. This appendix also contains a chapter on
Climates for Invalids, and one on Mineral Waters.
The book is certainly an excellent one of its class, but its usefulness to the
physicians of this country would have been enhanced if the American publishers
had secured the services of an editor. In looking over the prescriptions it is not
rare to find several on a page containing articles not officinal in the Pharmaco-
poeia of the United States, and in one or two instances they are wholly made up
of such preparations. An editor would probably also have rendered the book
more complete by the addition of a few remarks on the health-resorts and mineral
springs of this country. J. H. H.
Art. XLII. — The Fourth Annual Report of the Board of Health of the City of
New Haven, 1876. 8vo. pp. 64. New Haven, 1877.
Brief as it is, this report contains the matter often separately presented in regis-
tration reports. Its sanitary suggestions are sensible and practical, but present
little matter for special note or criticism.
The mortality reports present some points of interest. Measles caused 16 deaths
in the year 1876 (1.3 per cent, of all) against 1 in 1875. All occurred in the first
six months. Of 51 deaths from scarlet fever (4.13 per cent.) only 2 occurred
between May and November. The average number for ten years has been 59,
ranging from 98, two separate years, down to 3, in 1874 (8.66 per cent, to .28
per cent.).
Croup is debited with a mortality of 29, and diphtheria of 80 — the latter much
larger than ever before. Typhoid fever, on the contrary, shows in 1875 a de-
cided, and in 1876 a still more marked, decline, as a cause of death. Showing
in 1'867 and 1868 a percentage of 5.79 and 7.79, it then remained nearly station-
ary at 4 to 4.5 for six years. Then, as before noted, it fell in 1875 to 3.01, and
in 1876 to 1.79. Improved sewage of the city is noted as having probable influ-
ence ; but no data are given of any specially great works.
Of 124 children killed by cholera infantum — over 10 per cent, of all decedents —
79 died in July.
The mortality from consumption shows a curious irregularity, as here reported,
for ten years. Although the average percentage to all deaths is 14, and that of
1876 only 12.21, yet we can scarcely draw any favourable inference, since, though
he highest figure, 20.27, occurred in 1867, we find 9.83 in 1872 followed by 18.36
nl874.
Deaths from pneumonic congestion and inflammation are almost equally irregu-
lar, though presenting no apparent relation to the other series. The mortality
varies from 7.84 down to 2.34 in different years.
We are glad to notice that the health officer is a physician, and judge that Dr.
Lindsley is a zealous and intelligent incumbent. B. L. K.
1878.]
249
QUARTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES
IN THE
MEDICAL SCIENCES.
ANATOMY AND PHYSIOLOGY.
The Acidity of the Human Gastric Juice in a Case of Gastric Fistula.
M. Richet (Journal de Pharmacie et de Chimie, May) lias made researches
in a case of gastric fistula. The person experimented on had had gastrotomy
performed the previous year by Professor Verneuil on account of complete
closure of the oesophagus. The impermeability of the oesophagus is so much the
more interesting, as it prevented any admixture of the gastric juice with saliva.
This was proved by making the patient chew sugar mixed with ferrocyanide of
potassium, and finding no trace of this salt in the contents of the stomach. The
juice itself was collected after the stomach had been washed out with distilled
water, its secretion being excited by the presence of sapid substances in the
mouth. Thus obtained it is a colourless liquid, slightly ropy, easily filtered,
having little odour, and putrefying spontaneously. The average duration of the
sojourn of food in the stomach was 8 to 4 hours for such aliments as starch, fat,
and meat ; for milk, 1^ hours ; for water and alcohol, 30 to 40 minutes. At the
end of four hours the stomach was generally empty, and hunger did not super-
vene till two hours later. M. Richet thinks that the food does not leave the
stomach gradually ; it seems, on the contrary, to pass the pylorus en bloc, and all
at once. During the first three hours of digestion the volume of the mass does
not vary ; then abruptly, in a quarter of an hour or more, the mass disappears
entirely, only the debris remaining behind.
M. Richet arrives at the following conclusions: 1. The mean acidity of the
gastric juice, pure, or mixed with the food, is equivalent to 1.7 hydrochloric acid
for 1000 grammes of liquid (.17 per cent, of hydrochloric acid). It is never
lower than .05 nor higher than .32 per cent. 2. The quantity of liquid found in
the stomach has no influence on its acidity ; whether the stomach is full or almost
empty, its acidity is almost invariable. 3. Wine and alcohol increase, cane-sugar
diminishes, the acidity. 4. If we inject into the stomach acid or alkaline liquids,
the gastric fluids tend very rapidly to recover their normal acidity, so that at the
end of an hour the acidity will return to the mean. 5. The juice is more acid
during digestion than when this process has ceased. 6. The acidity increases a
little toward the end of digestion. 7. The sensations of hunger or thirst do not
depend on the state of acidity or on the emptiness of the stomach. — London
Med. Record, Oct. 15, 187 7.
250
Progress of the Medical Sciences.
[Jan.
MATERIA MEDIC A AND THERAPEUTICS.
On Hydrobromic Acid.
Mr. T. F. Abraham (Pharmaceutic a! Journal, Oct. 20) says: Hydrobromic
acid, or rather the impure solution thereof as produced by the process described
by Dr. Fothergill, seems to have firmly established itself as an useful agent in
combination with quinine. It is found that, in many cases, when the use of qui-
nine causes headache or other disagreeable symptoms, the addition of fifteen-
minim or twenty-minim doses of hydrobromic acid entirely removes the difficulty.
Whether its administration as an independent remedy will be found desirable, I
think still remains to be seen.
It must be, however, a matter of regret that the name should have come in
pharmacy to be applied to an impure and somewhat indefinite product. It is to
be hoped that, in our next appendix to the Pharmacopoeia a form will be intro-
duced that, while keeping pretty closely to the strength of Fothergill' s acid,
which I think has been found convenient, will furnish a fairly pure and definite
product. — London Med. Record, Nov. 15, 1877.
On Phosphate of Lime.
In an article in the Bulletin de Therapeutique, t. xc, MM. Paquelin and
Jolly arrive at the following conclusions : 1. Phosphate of lime is absorbed only
in very small proportion. 2. The organism in general consumes very little of it.
3. The circulation carries only insignificant quantities of the phosphate; with the
exception of the bones, our tissues contain, so to speak, only traces. 4. Lime
enters the organism in two states ; in small quantity, in the form of bisulpnate,
and in considerable proportion, in the form of salts that are not phosphates. A
part of the non-phosphorized lime-salts pre-exists in the food (carbonate of
lime) ; the other part is one of the products of the decomposition of the sulphate
of lime in the food by the acids of digestion (chloride of calcium, lactate of lime,
etc.). 5. The organism makes its phosphate of lime by a double exchange, and
finds in the food all the elements necessary for increasing the production of this
substance, according to its needs. 6. The greater part of the phosphate of lime
in the urine is found in the bladder ; and the whole of the salt in the urine is
therefore not a direct product of dis assimilation. 7. Of the two elements, phos-
phoric acid and lime, which enter into the composition of phosphate of lime, the
phosphoric acid is absorbed in certain proportions in the form of alkaline phos-
phate, while the lime is directly thrown out by the intestines. 8. The addition
of phosphate of lime to food is an obstacle to nutrition. 9. The soluble prepara-
tions of phosphate of lime act primarily as acids, and then, in consequence of the
changes which they undergo in the intestine, they act, secondarily, in a certain
measure, as phosphates having another base. — London Med. Record, Nov. 15,
1877.
Transformation of Salicylic Acid.
M. Byasson has sought to determine what are the transformations which sali-
cylic acid undergoes after being swallowed by man. Numerous experiments have
led him to the folloAving conclusions : Salicylic acid, swallowed by man in a state
of salicylate of soda, appears in the urine, and may be detected twenty-five
minutes after its demonstration by its reaction with perchloride of iron ; a dose of
forty grains is eliminated in from about twenty-six to forty hours. 2. In its pass-
age through the body, a portion of the salicylate is eliminated unchanged, another
1878.]
Materia Medica and Therapeutics.
251
portion is transformed into salicine, into salicyluric acid, and probably into oxalic
acid. 3. The first urine passed, some hours after ingestion of thirty to forty
grains of salicylate of soda, deviates to the left of the plane of polarization; the
deviation is due to the salicine produced. 4. The salicylic acid increases in the
urine the proportion of azotized substances and of uric acid. 5. Salicine swal-
lowed by man is eliminated unchanged, and with its optical properties, a few hours
after it is taken. But by what chemical reaction is this transformation effected of
salicylate of acid into salicine or salicyluric acid ? On this subject only theories
can be formed, but the fact is acquired to science.
A propos of the demonstration of salicylic acid, M. Gubler has remarked
that in certain cases the urine is diminished in quantity, whilst in others it is aug-
mented. When, indeed, salicylic acid acts upon normal kidneys, there is diuresis ;
on diseased kidneys, on the contrary, there is a diminution of the quantity of the
urine ; in these cases even albumen is sometimes found in considerable quantities.
There are, then, two indications here : first, strong doses of salicylic acid may
produce a renal lesion ; and further, when the kidneys are congested, it is impru-
dent to prescribe this medicine.
M. BuCQUOY supports this observation of M. Gubler, and asks if it is not from
uraemia that certain patients died so rapidly when treated with salicylic acid. He
mentions further the cases in which this substance was the cause of abortion at six
months. — Brit. Med. Journ., Nov. 8, 1877.
Mode of Action of Ancestlietics.
How do anesthetics act '? Is it by combining with certain elements of the gan-
glion cells of the central nervous apparatus, and thus, by altering their molecular
composition, preventing the generation of nerve-force, or interfering with its
manifestation ? Is it by modifying the circulation in the nerve-centres, or is it by
changing the composition of the blood, and rendering it less fit for the nutrition of
these highly complex structures ? Binz concludes an article on the officinal
sleep-producing substances in the Arcliiv fur Experimentelle Path. u. Pharm. by
saying that these agents possess the power of producing a kind of coagulation of the
substance of the cerebral cortex, whilst other agents, though nearly allied to the
former in chemical composition, do not possess this power. Morphia, chloral,
ether, and chloroform possess, he maintains, a strong affinity for the substance of
the cortex of the brain in man ; and when they are introduced into the blood they
enter into combination with the cerebral substance, opposing or impeding the dis-
integration of the living substance, and thus rendering it unfit to discharge the
functions required of it in the living state. In a paper on the same subject in the
Centralblatt Heixrich Raxke observes that protracted study of the effects of
anesthetics has led him to very similar conclusions. He has found that the action
of chloroform, ether, and amy! on frogs first produces a condition in which, just as
in poisoning by curare, no contraction can be induced in muscle by any kind of
irritation applied to the motor nerves, though the muscular tissue itself reacts to
direct stimulation, and the current in the nerves remains constant both in force and
direction. In a later stage of the anaesthesia the muscular tissue itself ceases to
respond to the most powerful induction currents, though its proper electro-motor
force remains unweakened ; and, lastly, at a still more advanced stage, the whole
muscular tissue of the body passes into a condition of rigor. He has further found
that a solution either of albumen from the brain or of myosin from muscle in very
weak salt and water is precipitated by the vapour of the three above-named anaes-
thetics, and that their power of producing muscle rigor in the case of muscle
depends on the coagulation of the myosin. It would have been exceedingly inte-
resting if the view of Binz to the effect that morphia acts also as a coagulating
252
Progress of the Medical Sciences.
[Jan.
agent upon the ganglion cells could be corroborated, since, if such were the case,
V would tend to show that the various kinds of anaesthetics act essentially in the
same manner.
Additional experiments have lately been instituted by Ranke, which demon-
strated that not only chloroform and chloral hydrate, when injected into the arte-
ries, caused rapid stiffening of the muscles, but that the same influence was exerted
by ether, amyl, bromoform, and bromhydrate, whilst when tannin, cupric sul-
phate, mercury chloride, ferric sulphate, or spirits of wine were injected, though
strong fibrillar contractions occurred, and coagulation of the blood, followed by
death, in no instance was rigor produced. Iodoform, indeed, appears to form an
exception to the conclusion that the rigor- producing action of the anaesthetics is
something peculiar to them, for it is not known to possess anaesthetic properties.
If injected in solution in ether, rigor is immediately produced, but ether has itself
a stiffening action on muscle. Nevertheless Ranke thinks he can distinguish be-
tween the action of the iodoform, which is immediate and intense, and that of the
ether, which comes on later and is less powerful; and he attributes the failure of
iodoform to act as an anaesthetic to its insolubility merely, which, as it were,
masks its proper action. Ranke was unable to find that solutions of morphia
were able to exert any coagulating influence on muscle either within or without
the vessels. It may be asked what relation does the action of these agents on
muscle bear to the process of anaesthesia, and in reply Prof. Ranke observes that
anesthetization obviously cannot depend on such a complete coagulation as admits
of no further change, since the effects produced by anaesthetic agents are but tran-
sitory. But it is very conceivable that an action which in its final stages leads to
coagulation of albumen may, in its earlier stages, render, to a certain extent, fixed
and immovable the albuminous molecules in the ganglion-cells of the brain, and
afterwards in nerve and muscle, the effect passing off with the removal of the
cause. — Lancet, Nov. 24, 1877.
Action of Pilocarpin on the Eye.
M. Galezowski, in a communication to the Society de Biologie {Gaz. des Hop.,
November 6), narrated the results of the trials he had made on the eye with pilo-
carpin, the. active principle of jaborandi. These show it to be possessed of power-
ful myotic powers. One drop of a mixture consisting of ten parts of water and
one-fifth of a part of pilocarpin, instilled into an eye the subject of paralytic my-
driasis, gives rise to such a contraction of the pupil that at the end of half an hour
this measures scarcely a millimetre in diameter, the contraction continuing for from
five to eight hours. This result has been verified upon a great number of patients,
so that it may be now stated that pilocarpin possesses myotic powers as active as
those of eserine, while it does not excite irritation like that substance, lh3 pro-
longed employment of which may give rise to peri-orbital pains, intense conjunc-
tivitis, and great nausea. M. Galippe observed that the experiments which he
and M. Bochefontaine had made were attended by precisely the same results as
those described by M. Galezowski. — Med. Times and Gaz., Nov. 17, 1877.
Sulphate of Atropia in Pathological Sweating.
M. Royet, in his thesis {Lyon M4d., Nov. 18), furnishes the results of the
trials made with this substance by Prof, Vulpian since 1873. These demonstrate
the efficacy of atropia in sweating under the most various circumstances — as
phthisis, rheumatism, convalescence, prolonged suppuration, hysteria, and the in-
fluence of jaborandi. The close of the sulphate varies from half a milligramme
to one and a half, it being very rarely desirable to go beyond this. The most
1878.]
Medicine.
253
convenient form to administer it is in pills or granules, each containing half a
milligramme. In order to act with efficacy, the medicine should be given a few
hours prior to the occurrence of sweating. Thus, in the nocturnal sweating of
phthisis, the pill should be given at eight or ten o'clock in the evening. At least
two hours should elapse between the do^es, and, if two or three are required in
the twenty-four hours, these should be divided by equal intervals. From two to
four days suffice to produce a suppression or notable diminution of the sweats ;
but, in order that the effect may be durable, the use of the atropia should be pro-
longed, with some diminution of the dose, for eight or ten days, The author of
the thesis agrees with Prof. Vulpian in believing that it is nowise imprudent to
suppress sweating in rheumatism. — Med. Times and Gaz., Nov. 24, 187 7.
MEDICINE.
The Excretion of Indican and Lime in Disease.
In an interesting communication to the Centralblatt Med. Wiss. (Nos. 20-22,
187 7), Professor Senator, of Berlin, sums up the main results of a series of obserT
vations on the excretion of indican by the kidneys which , he has made in more
than a hundred cases of diseases of various kinds. He also adds some remarks on
the excretion of lime in the urine in various diseased conditions. We may pre-
mise that these researches have a direct bearing on diagnosis, and are therefore oi
clinical as well as of scientific interest. " In general terms it may be stated,"
says Professor Senator, " that an abnormal excretion of indican occurs much more
frequently in chronic than in acute diseases, and it is especially in consumptive
states and wasting diseases that it is observed. Patients who can scarcely eat any-
thing, and who either vomit part of their food or else digest it badly, frequently
pass enormous quantities of indican in the urine, especially in comparison with
healthy persons taking the same or even a larger amount of food. The greater
the anaemia, the greater the excretion of indican generally becomes." Indican
excretion is enormously increased in diffuse peritonitis, and to a less extent in sub-
acute, and in certain cases of circumscribed peritonitis it is also considerable. In
other febrile diseases (pneumonia, pleurisy, meningitis) the amount of indican in
the urine is very frequently very large when compared with the small amount oi
nourishment taken by the patients ; and in typhoid fever there may even be an
absolute increase, whether diarrhoea be present or not.
Among chronic diseases, cancel- of the stomach, whether the neighbouring or-
gans be involved or not, is attended by the largest excretion of indican, and this
independently of the condition of the stools. Professor Senator examined twelve
cases of this disease, and in all the amount of indican was enormous. In ulcer of
the stomach the indican is also present in abnormal quantity relatively to the food
ingested, especially if there have been recent hamiorrhages ; the amount is, how-
ever, generally smaller than in cancer. Next to cancer of the stomach, the largest
increase in the excretion of indican is caused by multiple lymphomata and lympho-
sarcomata, especially when situated in the abdominal cavity. The urine of chil-
dren with glandular swellings and the symptoms of the so-called tabes mesenterica
is also often extraordinarily rich in indican, and it may be stated generally that in
a number of children's diseases indican is present in large quantities. In advanced
phthisis, especially where there is violent diarrhoea and amyloid degeneration of
the liver, spleen, and kidneys, indican is generally much increased. Amyloid
degeneration of the kidneys due to other causes, e. g. syphilis, causes no increase
254
Progress of the Medical Sciences.
[Jan.
in the amount of indican in the urine ; and the same is true of acute or chronic
diffuse parenchymatous nephritis. On the other hand, in four cases of granular
kidney, a large amount of indican was found to be excreted. In chlorosis, in the
various forms of leulccemia and j)seudo-leukcemia, and in progressive pernicious
anaemia, there is a moderate increase in the indican excretion: but even when tin-
amount of wasting and the loss of strength in pernicious anaemia exceed those in
cancer of the stomach, as far as Professor Senator's observations go, the excretion
never attains the same proportions as in the latter disease. The diagnostic value
of this fact, if confirmed by other observers, is self-evident. Intestinal obstruction
dependent on mechanical causes, or on intussusception, appears (in the absence of
cancer or peritonitis) not to cause much excretion of indican. In some cases
where there is an abnormal excretion of indican, there is a simultaneous increase
in the amount of lime in the urine. This is the case in phthisis, even where very
little food is taken, and in spite of the presence of diarrhoea. It also occurs in
children with multiple swellings of the glands and with rickets. In acute febrile
diseases, however, such as pneumonia or typhoid fever, the excretion of lime and
that of indican appear to diverge from one another, that of the former being di-
minished, and that of the latter increased. In pleurisy with effusion alone has
Professor Senator several times observed that there was an increased excretion of
lime, notwithstanding the presence of fever.
The method adopted in testing for indican in the above research was the fol-
lowing:— The urine is, if necessary, to be freed from albumen in the usual way.
and ten to fifteen cubic centimetres are to be mixed with an equal quantity of
fuming hydrochloric acid in a rather large test-glass. A concentrated solution of
chloride of calcium is then to be added gradually, drop by drop, until the blue
color of indigo is fully developed, and the whole is then to be shaken up with
chloroform. The latter takes up the freshly precipitated indigo, and sink< with
it to the bottom of the glass, where the amount can be estimated with a little
practice, in the same way as albumen is usually estimated, but far more accurately.
This remark applies to pale urines (which, as a rule, are the richest in indican).
Highly pigmented urines must be first decolourized by acetate of lead, avoiding
an excess of the latter reagent before applying the indican tests. — Med. Times
and Gaz., Sept. 22, 1877.
Diminution of the Acidity of the Gastric Juice in Febrile Conditions.
An interesting illustration of the relation of the hydrochloric acid of gastric
juice to the febrile process is afforded by a case reported by Dr. Vox den X el-
den, assistant to Professor Kussmaul, at Strasburg, in the Berl. Klin. Woch.
(Xo. 42. 187 7). The patient, a man of sixty, had suffered from gastric symp-
toms for about ten years, which latterly assumed the character of those of dilata-
tion of the stomach, pain in the epigastrium, repeated vomiting, etc., which
reduced his strength to such a degree that he was obliged to enter the hospital for
relief. He was admitted on February 27, 1877, and treated with the stomach-
pump with great benefit, and the disappearance of the vomiting. The fluid which
was pumped out (in the morning before breakfast) was generally quite clear, and
ranged in quantity between 100 and 700 cubic centimetres. At first it contained
sai-cinae and torulae, with abundance of peptones, and a gradually diminishing
amount of undigested food. The percentage of hydrochloric acid was determined
by Resch's colour test (described in the Zeitschrift fur Phys. Chemie, Bd. i. 3),
and varied between 0.025, 0.03, 0.05, 0.13, 0.15, 0.16, and in one instance 0.3
per cent. In May, when the patient's improvement had become so great that he
was about to leave the hospital, he began to suffer from diarrhoea, and on June 7,
headache, fever, and general malaise ushered in an attack of typhoid fever
1878.]
Medicine.
255
(source not stated), which ran a normal course, and terminated about the twenty-
second day. Daring the attack the stomach-pump was used daily before break-
fast, and the liquid removed carefully examined. In quantity it was less than
previously, and scarcely reached 100 cubic centimetres. The main difference in
its composition revealed by analysis was dhe absence of free hydrochloric acid,
although its reaction was faintly acid, probably from the presence of lactic or
acetic acid. A flake of fibrin remained quite undigested whilst in some of the
filtered liquid in the cold; whereas the addition of an equal volume of 0.2 per
cent, dilute hydrochloric acid caused its rapid disappearance. On the cessation
of fever, on June 7, Dr. Yon den Yelden naturally expected that hydrochloric
acid would again be found in the gastric liquid. He had, however, to wait until
the eighth day after the temperature had become normal before traces of it reap-
peared. On the ninth day 0.08 per cent, was detected, and from this time on-
wards the percentage ranged between the limits mentioned above. It might be
objected that since in this case the gastric contents were removed before food had
been ingested, the absence of acid might depend on the absence of a stimulus to
its secretion ; but this objection fails, because the patient happened one morning
to breakfast before being pumped, and still not a trace of free hydrochloric acid
was present. The absence of acid was also not due to the patient's diet during
the period of fever, for the latter consisted, inter alia, of milk, bouillon contain-
ing eggs, and other nitrogenized substances, in the presence of which acid juice
would normally be secreted. Lastly, there was no increased secretion of alkaline
mucus which would mask the free acid by neutralizing it as soon as secreted.
This case confirms the observations of Pavy, Hoppe-Seyler, Manassein, Leube,
Uffelmann, and others, that it is the acid, and not the pepsin, of the gastric juice
which suffers diminution in fever, and it suggests the more extensive use of hydro-
chloric acid during the period of elevated temperature. — Med. Times and Gaz.,
2s ov. 10, 1877.
4 Salicine in Rheumatism.
Mr. Samsox Gemvtell and Mr. Frank Shearer contribute a paper on this
subject to the Glasgow Medical Journal (Oct. 187 7), in which they give the fol-
lowing conclusions : —
1. In acute febrile articular rheumatism, free from all complications, salicylate
of soda is the most powerful therapeutic means which we possess ; it cures more
rapidly than any other.
2. It is impossible to assign to the treatment a uniform duration of days.
3. It does not prevent the cardiac, pulmonary, and cerebral complications of
acute rheumatism ; and where these exist prior to the treatment, it has no effect
on them.
4. In spite of its antipyretic properties, it does not hinder the ascent of the
temperature, which announces the advent of visceral complications.
5. In acute rheumatism, with slight complications, it is well to push the salicy-
late for its antipyretic and analgesic effects, but the use of revulsives should not
be forgotten.
6. In acute rheumatism, with grave complications, it is well not to rely on the
salicylate alone, but also to have recourse to other medicines.
Etiology of Typhoid Fecer.
M. Ch. Bouchard read before the International Medical Congress, at Geneva,
Sept. 12th, 1877, an interesting report on this subject, which is published in Revue
Mensuelle de Med. et de Chir. for Xov. The following are his conclusions: —
256
Progress of the Medical Sciences.
In the etiology of typhoid fever the doctrine of contagion and that of infection
are both too exclusive. The doctrine of its fecal origin does not correspond with
the universality of the facts. The doctrine of spontaneous development is not
proved. Typhoid fever is a specific, miasmatic disease.
In its production it so happens that the morbific matter coming, we know not
whence, but not necessarily from an infected organism, is capable of developing
itself in animal matters which become then a focus of infection, and in the living
human organism a focus of contagion. The contagion is almost always mediate.
The morbific matter arising from foci of infection, or of contaminated individuals,
may contaminate the air, the soil, or the water. This morbific matter may be
disseminated by men, by the contaminated objects, by the air, and especially by
drinking water. The influence of reservoirs and of defective sewers, neglected
or badly constructed, is shown, whether regarded as agents of infection or of medi-
ate contagion. The influence of variations of the level of the subterraneous sheet
of water is not clearly established.
Diphtheria complicating Enteric Fever.
At a late meeting of the Pathological Society of London (Lancet. Xov. 10.
1877), Dr. Greenfield showed a recent specimen of diphtheritic false mem-
brane in the larynx and pharynx from a case of enteric fever. The case was that
of a child, five years of age, who had been in St. Thomas's Hospital under the
care of Dr. Murchison for about fifteen days. There was swelling and slight
ulceration of Peyer's patches and solitary glands at the lower part of the ileum,
the ulcers being small, round, and sharply excavated. In the larynx, upper part
of trachea, and posterior surface of the palate and fauces, there was a thin layer
of false membrane and muco-purulent secretion. The exudation was met with
about the posterior nares and the orifices of the Eustachian tubes ; but there was
none on the anterior surface of the palate. Dr. Greenfield remarked that ulcera-
tion of the small intestines had been described in diphtheria, and he had often
seen swelling of the solitary glands of the ileum in that disease : but the«present
was undoubtedly a case of enteric fever, and the questions raised by the case were,
first, what was its relation to true diphtheria, and next whether diphtheria exists
as a distinct specific disease at all.
Dr. Murchisox said the patient in question was under his care at the hospital.
The case was one of enteric fever in about the third week. Another child in the
same family had recently had an abortive attack of enteric fever. In the present
case laryngeal symptoms came on two days before death. Xo membrane could
be seen on the fauces, which, with the tonsils, were red and swollen ; and he
hesitated to say whether the case was one of diphtheria complicating typhoid, or
one of the other laryngeal complications that may occur in that disease. In addi-
tion to the laryngeal symptoms, there were signs of consolidation of the lungs.
A form of diphtheria which he was in the habit of regarding as different from
true diphtheria was not an unusual complication of enteric fever, and more often
of typhus and scarlet fevers. Such cases occurred at the Fever Hospital, where
it was curious that very few cases of diphtheria itself were admitted.
Dr. F. Semox had seen, both here and in Germany, cases of diphtheria compli-
cating typhoid ; and, as a rule, in such cases, the diphtheritic inflammation begins
in the larynx and spreads upwards, but does not affect the upj)er part of the pha-
rynx.
Dr. Murchisox added that even when the laryngeal symptoms were severe,
there had been no difficulty in swallowing. One of the members of the family had
died of enteric fever. In reply to Mr. Pugin Thornton, he said that as a rale the
complication occurred about the third or fourth week of the fever.
1878.]
Medicine.
257
Dr. Clifford Allbut remarked that diphtheritic complications of typhoid fever
seemed to occur in some epidemics and not in others. He had been led to the
opinion that there was some relation between enteric fever and diphtheria, partly
from the above fact, and partly because diphtheria springs up in the same locali-
ties as typhoid does, and under similar conditions. He instanced the occurrence
of an epidemic of diphtheria in a Yorkshire village being shortly followed by an
epidemic of typhoid.
The Therapeutics of Diphtheria.
Mr. J. Graham Brown, Senior President Royal Medical Society, Edinburgh,
publishes in the Journal of Anatomy and Physiology (Oct. 1877) a series of ex-
periments which he performed in Prof. Klebs's laboratory in order to ascertain
what drugs seemed to have an influence over the diphtheritic process. His detailed
experiments seem to indicate. —
(1.) That the contagious fluids of diphtheria are rendered powerless to propa-
gate the local disease after mixture for a longer or shorter time with solutions of
hydrochlorate of quinia, salicylate of soda, and benzoate of soda.
(2.) That the most powerful of these three is benzoate of soda.
(3.) That the administration of benzoate of soda hypodermically, previous to
the inoculation of diphtheria, has a power of preventing the establishment of the
disease : but that this protection only extends to a certain length.
Mr. Brown very properly remarks that it would be very rash to suppose that
any one of these points has been firmly established by the amount of evidence
which is contained in this research. There are so many sources of error ever
present as to preclude such a possibility. Still, however, the uniformity of the
results obtained is so striking as to increase greatly their value.
On the Use o f Iron in Epilepsy.
Dr. W. R. Gowers. Assistant Physician to University College Hospital, in
an interesting article ou this subject (Practitioner, Oct. 1877), thus summarizes
the important facts regarding the use of iron in epilepsy : —
1. In a certain proportion of cases of epilepsy, which are probably a minority
of the whole group, iron does increase the frequency and severity of the fits.
2. In a large number of cases iron may be given without any recognizable in-
fluence on the attacks.
3. In many of the cases in which its effect is injurious, the increase in fits does
not occur until after the iron has been taken for some weeks, and in some of
these cases the first effect of the drug is to cause a diminution in the frequency
and severity of the attacks.
4. In some cases this beneficial effect, instead of being transient, is permanent ;
and great benefit results from the continued administration of iron, so that by its
use alone some cases may be cured, as far as the affection can be said ever to be
cured by drags.
With regard to the indications for the use of iron, Dr. Gowers thinks that it is
certainly most frequently useful in the anomalous forms of epilepsy which stand
midway between epilepsy and hysteria, and have long been • known by some
mixed term, and in which co-ordinated and apparently purposive spasmodic
movements are part of the phenomena of, or commonly succeed, the "epileptic"
portion of the attack. Whatever be the exact nature of these cases, many are
certainly benefited in a remarkable degree by iron. The cases narrated show,
however, that it may also do good when the attacks are of a more purely epileptic
type. Anaemia, as an indication for the use of iron, is, Dr. Gowers thinks, of
No. CXLIX Jan. 1878. 17
258
Progress of the Medical Sciences.
[Jan.
less value in epilepsy than in other diseases. The facts he adduced suggest the
conclusion that iron has an influence on the nervous system analogous to that ex-
erted by zinc, silver, and some other metals, and that it is to this rather than to
its ha3matinic influence that the beneficial effects of its administration are due.
Treatment of Croup.
Dr. S. Oldoini relates in the Annali Universali for March, five cases of
croup observed during the epidemic at Spezzia, in which he successfully em-
ployed copaiba and cubebs. His plan was to give to adults, every two hours, a
dessert-spoonful of a syrup composed of 14 grammes (about 5 ounces) of balsam
of copaiba, 20 grammes (about 7 ounces) of powdered gum, 50 grammes (about
17^- ounces) of water, and 14 drops of essence of mint; and also, every two
hours, a table-spoonful of a mixture consisting of 12 grammes (18G grains) of
recently powdered cubebs and 240 grammes (8 ounces) of syrup. For children
the dose was reduced. The malady disappeared in a period of two or three days,
rarely extended to seven.
Four of the five cases were children under four years of age ; some affected
with simple croup, others Avith croup complicated with diphtheria. The con-
dition of the patients when first put under treatment was very grave ; there was
high fever, the submaxillary glands were engorged, the voice and crying were
weak, the cough harsh, and there was marked dyspnoea. The beneficial effects
of the medicine above described occurred without the use of emetics, mercurials,
or any other treatment. — London Med. Record, Oct. 15. 1877.
The Etiology of Pneumonia.
In the last part of the seventieth volume of Virchow's Archiv, Dr. Bernhard
Heidenhain discusses the question which has lately received much attention,
whether pneumonia is to be regarded as an infectious disease or not. A negative
conclusion would undoubtedly be arrived at if it could be shown that a non-spe-
cific lesion was capable of exciting an attack of true croupous pneumonia, and
Dr. Heidenhain set himself to experiment on this point in the Pathological In-
stitute of Breslau, under the guidance of Dr. Cohnheim. After some considera-
tion, the simplest method of affecting the lungs appeared to be to make the animal
breathe hot air, and with this object a canula was introduced into the trachea con-
nected with a tube, a portion of which could be heated at will. The experiments
lasted fifteen and thirty or more minutes. In the course of three, five, or seven
days the animal was killed, but in all instances the lungs were found to be per-
fectly healthy. In other instances the animals were made to breathe ice-cold air
from a tube which passed through a refrigerator. The effects were here, how-
ever, also negative, nor was any pneumonic inflammation established when the
animal breathed an artificially-heated and cooled atmosphere alternately for
periods of about a quarter of an hour each. Some explanation of the absence of
all inflammatory reaction in the deeper parts of the lungs is gained, from the fact,
which he ascertained by an ingenious arrangement of thermometers, that dry air,
if heated rapidly, parts with its heat, or if cooled rapidly, acquires the tempera-
ture of the body in passing down the trachea, so that the deeper parts of the lungs
are never exposed to very hot or very cold air, however high or low, within, of
course, certain limits, the temperature of the air may be, provided it is dry when
inspired, a point of some importance in pathology. If the ah- be moist to begin
with, the results are different ; for then, if breathed at a temperature above 130°
Fahr., the lungs begin to be affected, the condition established resembling that
of catarrhal pneumonia. The vapour of acetic acid produced effects similar to
1878.]
Medicine.
259
those of hot moist air. Heidenhain found it to be impossible to experiment with
other gases, such as chlorine, for either they proved rapidly fatal, or if so diluted
as to be without influence on the general economy, the lungs also remained
intact.
Heidenhain' s researches, therefore, lead him to the conclusion that true croup-
ous pneumonia cannot be excited by irritation of the respiratory passages. If, he
says, we are to regard as essential features of croupous pneumonia that one lobe
of a lung or part of a lobe (lobar pneumonia) should be affected throughout its
whole substance, that there should be coincidently pleurisy, that the trachea and
bronchi should remain intact, or at least be only secondarily affected, then he has
been unable in any of his experiments to establish that disease. In all cases
where any disease at all was produced, the trachea and bronchi were primarily
and the lungs were secondarily affected, and the affection of the lung presented
in all cases essentially similar characters. There were more or less numerous
small foci of disease which corresponded with what in human pathology would be
called catarrhal pneumonia or broncho-pneumonia. Pleurisy was invariably ab-
sent. The general result, therefore, arrived at by Heidenhain is rather in favour
of the existence of some specific agent as the cause of pneumonia. — Lancet, Sept.
1, 1877.
Cold Washings and Douches in Tuberculosis.
Dr. Pogacnik, of Vienna, in the Allgemeine Wiener Medizin. Zeitung for
August 21, alleges that he recommended water treatment in tuberculosis in the
form of cold frictions before Brehmer commenced his douches (see Monthly Ab-
stract of Medical Sciences, Dec. 1876, p. 554), and strongly maintains the supe-
riority of his plan, which is as follows: —
The patient, on waking in the morning, strips, and, standing on a dry cloth,
sponges himself all over with water varying in temperature from 10° to 20°
Reaumur (55° to 7 7° Fahr.), according to the temperature of the air at the
time. He then rubs himself down with flesh gloves for about five minutes, com-
pleting the drying process by envelopment in a linen sheet. He returns to bed,
and remains there from half an hour to an hour well covered up, though not suf-
ficiently to induce perspiration. While reaction is going on, it is necessary that
the lung movement should be reduced to a minimum.
Dr. Pogacnik was led to the adoption of cold water frictions in tuberculosis by
observing their good effect on scrofulous glands, which, he states, diminished
more rapidly under their use than under a trial of iodine or cod-liver oil, and he
declares that his results in tuberculosis of the lung are not less favourable. The
influence of this treatment is : —
1 . To promote normal action of the skin ;
2. To relieve congested states of the lung by derivation to the skin ;
3. To harden the patient, and thus enable him to pass more time in the open
air ;
Increase of appetite and strength, with a lowering of the temperature, are
stated to follow ; but these improvements are not to be expected where the pul-
monary lesions are very advanced, or where the blood is disorganized ; but the
treatment is not contraindicated in haemoptysis.
Brehmer has advocated the use of local douches for the same purposes, but Dr.
Pogacnik claims the following advantages for his method : —
1. Cold frictions may be persevered with in haemoptysis when douches are im-
possible.
2. They are more agreeable to patients.
260
Progress of the Medical Sciences.
[Jan.
3. Their influence is more prolonged, and therefore more likely to be bene-
ficial.
4. They are easily procured, even among the poor, and while travelling,
whereas douches can only be obtained in institutions and large establishments.
5. The douche necessitates walking exercise after its use, which exactly re-
verses the desired effect on the body ; for by this the lungs, which have been re-
lieved by the cutaneous reaction, are brought again into full movement instead of
remaining comparatively passive, as is desirable. — London Med. Record, Oct.
15. 1877.
The Use of Digitalis in Disease of the Aortic Valves.
Dr. J. Melnek Fothergill, Assistant Physician to the West London Hos-
pital, sums up (British Med. Journal, Oct. 13, 187 7) the value of digitalis in
aortic valvular disease.
1. Digitalis is useful in aortic stenosis. By exciting a more powerful ventricu-
lar contraction, it enables an equal bulk of blood to be driven through a narrowed
orifice in an equal time, thus establishing a new equilibrium.
2. In the earlier stages of aortic regurgitation, with massive hypertrophy, it is
harmful rather than useful.
3. In the later stages of aortic regurgitation, where the heart is failing from
nraral decay, and especially when intermitting, digitalis may be given with at
least temporary advantage.
Complete Obliteration of the Aorta.
Dr. Wickham Legg, at a late meeting of the Pathological Society of London
(Lancet. Oct. 20, 1877), showed an example of complete obliteration of the
aorta, at the usual site — viz.. just in the neighbourhood of the ductus arteriosus.
The subject of it was an adult who had died suddenly from rupture of a dissecting
aneurism of the aorta into the pericardium. The vessel was completely oblite-
rated for about a quarter of an inch just beyond the ductus arteriosus, which per-
sisted as a ligamentous cord pervious for a short distance to a bristle. The circu-
lation was carried on by the anastomoses between the internal mammary and
other branches of the subclavian with the epigastric and intercostal vessels. Dr.
Legg believed that as many as eighty such cases had been recorded, and he referred
to the two existing theories as to the mode of origin of the constriction. The one
view is that it depends upon some condition of the ductus arteriosus, and the case
of a child is recorded in which a thrombus was found extending from the ductus
into the aorta. The other view — that of Rokitansky and Peacock — is that it is
dependent rather upon an original vice of development, and Dr. Peacock had
shown that it frequently went with other malformations, such as deficiency in the
ventricular septum or the presence of only two aortic valves, as in the specimen
exhibited.
Dr. Couplaxd mentioned a case recently in the Middlesex Hospital, under the
care of Dr. Thompson, in which this condition was marked during life by ex-
tremely tortuous and dilated arteries in the scapular and interscapular regions,
having the characters of cirsoid aneurisms. In this case the occlusion was not quite
complete, but the anastomoses were very abundant, the upper intercostal arteries
being of great size and very tortuous. Dr. Coupland referred to a case related
by Mr. Sydney Jones, in which the anastomoses were carefully dissected and
described.
Mr. Sydney Joxes said the preparation from that case, which he had brought
before the Society twenty years ago (see Transactions, vol. iii. p. 159), was in the
1878,]
Medicine.
261
museum of St. Thomas's Hospital. It occurred in a dissecting-room subject, a
man of the age of forty-five, and he was enabled to make a complete dissection of
it. In his paper he expressed concurrence in the view adopted by Dr. Craigie
that "the obliterating action, which has taken place in the ductus arteriosus, has,
from some cause or other, been prolonged within the aorta."
Mr. Wagstaffe asked Dr. Coupland whether the physical signs were sufficient
to render a diagnosis possible, to which the latter replied in the affirmative, add-
ing that he believed the condition had been diagnosed. Dr. Legg said that
Oppolzer had made the diagnosis in five or six cases, basing it chiefly upon the
absence of an aortic pulse in the abdomen, and the presence of the anastomoses.
Dr. Fagge reminded the members that Dr. Walshe had correctly diagnosed a
similar case, laying stress upon peculiar murmurs in the back.
[The late Dr. Cammann. of Xew York, is said to have diagnosed a case eleven
years before death, see Meigs's report of a case in the Amer. Journ. of Med. Sci.,
Jan. 1869, p. 31.]
Treatment of Neurosis of the Stomach.
In the treatment of dysorexia, says Dr. H. Lebert (Archives Gin. de Med.,
June, 1877), in a memoir on Xeurosis of the Stomach, the regulation of the diet
is the essential point to be attended to. Whilst variety should be permitted, all
indigestible and innutritious substances should be interdicted. In bulimia a little
food may be given between the ordinary meals, as two or three biscuits soaked in
sherry, and a cup of milk may be placed beside the bed at night, but no cooking
should be allowed. Moral treatment, gentle but firm, is indispensable. In this
condition M. Lebert has found opium or codeine in small doses, as one-sixth of
a grain three or four times a day, most serviceable. Bromide of potassium is
also useful in doses of five grains or more, or a drachm of the syrup ; the same
treatment is adapted for heterophagy. Where these means fail and the patient
continues to eat improper substances, small quantities of tartar emetic should be
surreptitiously added to them, that a cure may be effected by the vomiting
induced. Geophagy has become a more rare affection since the emancipation of
slaves and the better food they have obtained, and it will, he thinks, disappear
altogether. For its treatment repose, pine air, and a carefully augmented milk
diet, are all that is needed. A little rum or good wine may be added if the
patient be much exhausted ; more solid food may alternately be had recourse to,
and tonics may then be given, beginning with infusions of centaury, orange peel,
calumba. and quassia, and passing on to quinia and chalybeates. In gastraJgia
not only the diet but the whole hygiene of the patient must be attended to : milk
and farinaceous food, eggs, stewed meats, fish, young and tender vegetable food
may be given, but the use of tea, coffee, wine, and brandy, unless in very small
quantity, should be stopped. Cacao deprived of its fat can in general be taken, as
may also small amounts of aerated waters ; indigestible substances like legumes,
fat meats, ham and pork, are as a rule very inappropriate. The exercise should
be regular and moderate, and the advantage of moderation in amusements strongly
impressed on the patient. Great benefit is sometimes derived from hydropathic
treatment earned out with judgment. In regard to remedies, whilst none should
be prescribed that are not absolutely necessary, it is expedient to have several
resources against this frequently rebellious disease. We may commence with bis-
muth, small doses of nitrate of silver and bromide of potassium, and proceed to
the preparations of zinc, to mix vomica, and arsenic. Bromide of potassium,
which is not good in chronic catarrh of the stomach, is often very useful in pure
gastralgia. The sulphate, or better still the lactate of iron, may be prescribed in
doses of half to one grain several times a day. When the patient is troubled with
202
Progress of the Medical Sciences.
[Jan.
eructations they may be temporarily prevented by the administration of from fif-
teen to twenty grains of the bicarbonate of soda, but it soon loses its effect. M.
Lebert has not seen much advantage accrue from the use of valerian, castor, or
the fetid gum resins, though occasionally a combination of tincture of valerian
with bcnzoated tincture of opium has proved effective. In regard to local means
the hydropathic compress, either cold or allowed to remain as a poultice, is most
useful. Local faradization sometimes removes the pain, and in rebellious cases a
large flying blister may be applied to the epigastrium, with or without the subse-
quent administration of morphia in powder. Vomiting in gastralgia is usually
slight and transient, but it should be treated with ice internally and effervescent
drinks ; opiate injections and poultices, over which a little tincture of opium lias
been sprinkled, may also be used. If the attack have been brought on by some
imprudence in diet, the patient should be directed to drink abundantly of chamo-
mile tea, and a small dose of apomorphine be injected under the skin to promote
vomiting. — Practitioner, Aug. 1877.
Case of Obstruction of tlte Bowels by a Dislocated Spleen.
Dr. Victor Babesiu, of Pesth {All gem. Wiener Med. Zeitung, Sept. 1877),
publishes a remarkable case of a woman, aged 30, who was admitted on the 10th
of August with stercoraceous vomiting, and other symptoms of intestinal obstruc-
tion, which were quickly followed by collapse, and death occurred on the 13th.
The spleen, which was not enlarged, lay in the left inguinal region, parallel to
Poupart's ligament, and was adherent by bands of connective tissue to the groin,
the rectum, the spinal column, the coils of the ileum, the great omentum, the sig-
moid flexure, and to the brim of the pelvis, the uterus, and with the Fallopian tubes
and ovaries on both sides. Its under surface formed with Douglas's space a cavity
which was filled with ichor, and the walls of which were rotten, and covered with
dirty brown false membranes. The gastro- splenic omentum was stretched into a
cord about as thick as the little finger, seven centimetres long : the splenic vessels
were obliterated. The spleen itself was gangrenous. A loop of jejunum was
constricted between this ligamentous band and the spinal column. — Land. Med.
Record, Nov. 15, 187 7.
Localized Peritoneal Exudation which Perforated the Lung and Simulated
Pyopneumothorax.
This case is recorded by Pfahl in the Berliner Klinische WochenscJirift, Xo. 5,
1877. A Polish maid-servant, aged 23, was admitted with all the signs of right-
sided pyopneumothorax, with succussion-sounds and amphoric respiration. The
previous history of the case was imperfect, and only the physical signs were avail-
able for the formation of a diagnosis. The post-mortem examination revealed
the nature of the case. There had been a perforating duodenal ulcer, leading to
abscess between the right lobe of the liver and the diaphragm. This had pushed
up the diaphragm, displaced the heart to the left and upwards, and caused bulg-
ing of the right side of the chest. An adhesive diaphragmatic pleurisy had fol-
lowed, and the abscess opened into the lung. Thoracentesis was performed in
the fifth intercostal space, and after the evacuation of nearly two pints of pale
yellow offensive fluid the respiration became troubled ; and, in spite of free stimu-
lation, the patient died in ten minutes after the conclusion of the operation.
[The aids obtained from the case towards the correct diagnosis in any similar
one seem few indeed, but allusion is made to the fact that the heart was displaced
upwards, whereas in pneumothorax it should be dragged downwards. It maybe
doubted whether this is a point which could be relied upon.
1878.]
Medicine.
263
The author remarks upon the rarity of such cases, and mentions the only two
cases in any way like his which he has been able to find on record. One is by
Wurtrech in Virchow's Handbuch der Speciellen Pathologie und Therapie
(Krankheiten der Respirations-Organe), the other by Sturges in the Lancet.
He does not appear to be conversant ,with an article by Dr. Hilton Fagge in
the Guy's Hospital Reports, vol. xix., 1874, entitled "Cases of Abscess within the
Upper Part of the Abdomen." In that paper sixteen cases are collected, several
of which opened into the lung or pleura. It appears, it is true, that only one
gave any, and that but doubtful, evidence of pneumothorax ; but, after all, that
occurrence is but a side issue. Given an abscess between the diaphragm and liver,
or spleen and diaphragm, and it is not unlikely to open into the chest, though it
seems but rare that the abdominal are quite subordinate to the thoracic symptoms.
This is the clinical fact of importance. It may or may not produce symptoms of
pneumothorax.
Such cases have been but rarely recorded in medical literature, but that is pro-
bably, as Dr. Fagge remarks, because "their symptoms and course are so varia-
ble, and the publication of isolated instances might well appear likely to be of
but little service in facilitating their recognition by other observers, or in gaining
for them a place in scientific works on medicine." They have not been published,
but they are not very rare. They more commonly result from external injury,
or, as in Pfahl's case, by extension from disease in some neighbouring organ.
The reporter is, however, inclined to add that whenever a general peritonitis leads
to the production of much inflammatory effusion, whether it be lymph or pus, the
fluid gravitates behind and above the liver and to other dependent parts, and niay
then become shut off by adhesions and produce a local abscess. The reporter has
several times seen post-mortem evidence of a general peritonitis localizing itself
in this way under the diaphragm, above the liver, once above the spleen.
Dr. Fagge refers to a very important point, viz., whether the prognosis in these
cases is not really hopeful if they be recognized early, and the pus evacuated by
aspiration ; but enough has been done in alluding to his paper in its bearing on
the present case, and it can be consulted by any one interested in the subject who
is ignorant of or has forgotten its existence. In the same volume of Reports is
also a paper by Dr. Frederick Taylor on the same subject.] — London Medical
Record, Oct. 15, 187 7.
Lodic Purpura.
In a paper contributed to the Revue Mensuelle de Med. et de Chir., Sept.
1877, Prof. A. Fournier, of the St. Louis Hospital, observes that while among
the numerous and various phenomena which may follow the ingestion of iodide
of potassium, there are some which are of common occurrence and well known,
there are others which have either escaped attention, or have only been imperfectly
described. Among these may be ranged, he believes, a cutaneous affection, con-
sisting in the production of small miliary, non-pruriginous, sanguineous spots,
proceeding after the manner of purpura, and to which he proposes to give the
name of iodic purpura, or petechial iodism. That the appearance of the exan-
them and the taking the iodide are not a mere coincidence, he concludes from
the following observations : 1. In all the cases the purpura has appeared a very
short time (from one to six days) after commencing the iodide. 2. In some of
the patients the same purpuric eruption has been produced several times after
each new administration of the iodide ; and in three of these it occurred every
time the medicine was used. Two cases are detailed, in which this was the case
three or four times. 3. In another case, in which the purpura was produced on
three successive occasions, it was found in all these that whenever the dose was
264
Progress of the Medical Sciences
[Jan.
notably increased, a marked aggravation or additional production of the eruption
ensued.
As to the characteristics of this eruption, in all the patients the well-known
appearances of purpura, and the impossibility of effacing them by pressure with
the finger, were distinctly present, the petechial colour due to extravasation being
verv obvious. The seat of the eruption, with one exception (when it was on the
thorax, and that only), was in all the cases on the legs only, being always more
confluent on their anterior than on their posterior part. It never descended to
the foot or extended beyond the knee. This purpura seems to assume an emi-
nently discrete form, few spots being usually observed, about a hundred of these
on each limb constituting the maximum of confluence — fifty or sixty, or even
less, being the number usually observed. On the successive appearances the pur-
puric spots are even yet fewer in number. This rarity of confluence, and the
especial localization of the exanthem about the anterior tibial region, impart to
this variety of purpuric affection a somewhat peculiar physiognomy of its own.
It is always a miliary purpura, that is, a petechial eruption of the smallest extent,
resembling in size a millet-seed, the head of a pin. or at most, and that rarely, a
grain of corn or a small lentil. The spots are usually of a regular rounded form,
and less often oval or irregular in form and notched. The eruption never ad-
vances beyond this petechial and miliary condition. The spots are quite level
with the skin, seemingly incorporated with the integument, the appearance of
which they only modify by their bright colour. Like as in purpura vulgaris,
these spots give rise to neither local nor constitutional disturbance, inducing
neither heat, pain, nor pruritus. Thus there is a great chance of this eruption
passing unperceived ; and it is always by accident that the patients have observed
its existence, while undressing, at the bath, etc., so that many cases lnrve no
doubt escaped the notice of patients and their attendants. The eruption comes
on at an early period of the iodide treatment, and has completed its course in two
or three days, at the end of which period it ceases to increase in confluence, even
when the use of the medicine is continued. It remains for a certain time in the
condition of purpurine petechia?, after which the spots undergo the ordinary
chano-es of colour observed in cutaneous hemorrhages, finally disappearing at the
end of two or three weeks. When, under the influence of a large dose of the
iodide, a new purpuric outbreak is produced, the intruding eruption is easily dis-
tinguished from that which has preceded it by the bright purpurine colour of its
spots, contrasting with the faded condition of the prior spots. It has a curious
appearance, this intermixture in the same locality of petechias of different age?,
with differences of colour corresponding to the periods of their appearance.
This purpura is certainly a rare accident, or rather phenomenon, for there are
few remedies which are more employed than the iodide of potassium ; and if iodic
purpura were not almost an exceptional occurrence, it must have attracted the
attention of observers. Professor Fournier, who, during the few years since he
first became aware of its existence, has carefully sought for it, has not met with
more than some fifteen cases. It would be premature, with so small a number
of facts, to define the conditions which may act as predisposing or occasional
causes of its production ; but some etiological data may. perhaps, be derived from
the cases already observed. A priori one would be inclined to believe that a
predisposing and adjuvatory cause would be found either in the impoverished.
ana?mic, or debilitated condition of the patients, or in some of the graver forms
of syphilis. This is far from being the case. All the subjects of the affection
hitherto met with enjoyed either a flourishing or a medium condition of health ;
and although some of these seemed affected with a certain degree of " lymphat-
ism," none could be said to suffer from anseniia or scrofula, and none had pre-
1878.]
Medicine.
265
sented anterior hemorrhagic proclivities. Any of these who were the subjects of
syphilis exhibited only benign or medium forms of this : two- thirds of the cases
being exempt from any specific manifestation of this disease at the time -when the
iodide, which in fact was only administered as a preventive, produced the pur-
puric eruption. Further, in a negative point of view, neither sex. age. occupa-
tion, nor external temperature seemed to have exerted any influence. Xor can
the eruption be attributed to excess of dose, since most of these patients had not
taken more than fifteen grains of the iodide when the eruption had manifested
itself. Still, quantity is not a matter of indifference, for when a given dose has
been followed by purpura, a kind of tolerance of the remedy seems to be estab-
lished, and no further manifestation ensues. But let the dose be much increased
— doubled, for example — and a new outbreak of purpura may be inmiediatelv
produced. although this is less confluent and less important than that which pre-
ceded it. But it is probably the individual predisposition which predominates
over all the etiology, for however unknown and impenetrable in then' nature, the
existence of idiosyncrasies in regard to the action of certain remedies and articles
of diet is beyond doubt. Iodic purpura in its nature takes its place in the group
of affections termed by M. Bazin prdvoquges indirectes- or pathogenetiques. It
is a medicinal eruption, which ranges nosologically with the roseola from copaiba,
the erythema from belladonna, the exanthems from arsenic, the acne from iodine,
etc. — Med. Times and Gaz.. Oct. 20. 1677.
Moll uscum Contagiosum.
Kaposi (Archivfur Dermatologie und Syphilis, 3 Heft. 1877) proposes that
the molluscum contagiosum of Bateman shall be known as molluscum atheroma-
tosum, to distinguish it from the molluscum contagiosum of modern authors which,
from its wart-like appearance, is known as molluscum verrucosus. These varie-
ties are essentially the same anatomically, both being affections of the sebaceous
glands. In molluscum atheromatosum the gland itself is chiefly affected : in
molluscum verrucosum the morbid changes begin in the ducts and lanugo hair-fol-
licles, from which they extend to the glands.
The ''molluscum corpuscles" of authors are epithelial cells with altered cell-
contents.
Kaposi does not believe that the disease is contagious, and proposes that the
term contagiosum should be no longer used. — Load. Med. Record. Xov. 15, 1877.
Lichen Ruber Acuminatus and Lichen Ruber Planus.
Kaposi {Wiener Medizinische Wochenschrift, Xo. 35, 1877) remarks that
English and American writers, in substituting the name lichen planus for lichen
ruber, confound two distinct forms of the disease. In that originally described by .
Hebra the characteristic papules are red. pointed, conical, and have scales. They
do not occur in groups. There is another form, which has been described by
English- writing dermatologists, and which Kaposi infers they have alone observed.
In it the papules are flattened, do not scale, and have a tendency to form groups
or plaques. For this latter form the author recommends the exclusive use of the
term lichen ruber planus ; for the former, lichen ruber acuminatus. The distinc-
tion, he observes, is recognized by Hebra. The author gives details of cases of
lichen ruber planus observed in Vienna, and also remarks that in some of the
cases intermediate forms are observed, both varieties being in one instance found
on different parts of the same patient. In both varieties the disease yields to
arsenic. — London Med. Record, Xov. 15, 1877.
266
Progress of the Medical Sciences.
[Jan.
On Zoster Recidivus.
Kaposi gives (Wiener Mediziniscke Wochenschrift, Xos. 25 and 26, 1877) a
further report of a remarkable case of zoster to which he first called attention in
the same journal in 1874. The patient, a woman aged 42 at the time of her first
attack, has had now nine relapses of herpes zoster. The case began as one of
herpes zoster cervico-brachialis gangrsenosus dexter. The first relapse was on the
same part, but also in the region of the fourth and fifth ribs. The third and
fourth attacks were limited to the forearm and lower part of the arm. The fifth
extended over the shoulder and neck, between the seventh cervical and second
dorsal vertebras, and also over the anterior pectoral region over the fifth and sixth
ribs. All these eruptions were on the right side, and, with the exception of
patches over the left scapula during the first attack, and on the region between
the third and sixth ribs during this and the fifth outbreaks, in the same nerve-
territory, that, namely, of the right cervico-brachial plexus. The subsequent at-
tacks were on parts supplied by other nerves. The sixth was a zoster lunibo-
saero-cruralis of the right side ; the seventh, eighth, and ninth zoster cervico-
brachialis of the left side. Each attack ran the ordinary course of herpes zoster.
The author speculates on the probability of the phenomena in this singular case
being produced by a vascular tumour of the spinal cord. — London Med. Record,
Nov. 15, 1877.
Acetic Acid in Psoriasis.
Dr. Jansen (Revue Midicale) finds acetic acid the most effectual application.
After a bath of hot water and soap to soften the crusts, the scales are to be re-
moved by a small brush. The acid is then applied by means of a sponge. Very
soon the affected parts become pale, then injected, and finally slightly inflamed.
There is a feeling of smarting, which lasts half an hour. The crusts fall off, and
in some cases appear no more after the fifth or sixth application ; in others they
reproduce themselves for a longer time, gradually becoming less and less thick.
Only one application in the twenty- four hours should be made, and the parts
carefully bandaged. — Lond. Med. Record. Xov. 15, 187 7.
On Cysticerci in the Skin.
Guttmann (Berliner Klinische WocJienschrift, Xo. 26, 1877) reports a case
of this nature. He remarks that hitherto only sixteen cases have been published
in which cysterci have been found in the skin during life, only one being reported
from Austria and none from England.
His patient, a tailor 63 years old, first observed at Christmas, 1876, that there
were a number of small tumours under his skin. They produced no symptoms,
and were discovered accidentally. AYhen seen in February, 187 7, 20 of these
small tumours were counted, and a few weeks later 30. They were found chiefly
on the back, then the chest, neck, arms, abdomen, and right gluteal region. They
lay immediately under the skin, which was slightly raised by the larger of them,
were movable, felt tense and elastic, were of almost cartilaginous hardness, pain-
less on pressure ; they were chiefly round, but some were elongated, and were of
the size of a cherry-stone or small hazelnut. They were examined microscopi-
cally. The mode of infection was not ascertained. — London Med. Record, Xov.
15, 1877.
On OEdema and the Lymph-stream in Inflammation.
Dr. O. Lassar (Virchow's Archiv, March, 1877) gives an account of his ex-
perimental researches on this subject. He produced inflammation in the hinder
extremity of dogs by injecting a 20 per cent, emulsion of petroleum or oil of tur-
1878.]
Medicine.
267
pentine. One injection causes an abscess ; repeated injections cause diffuse sup-
puration. Or lie used Cohnheim's method of ligaturing the limb, and leaving it
for five or six minutes in water, heated to 50° or 54° Cent. (122° or 129° F.).
The animals were all large, strong, young dogs, and were curarised, respiration
being kept up artificially. It is essential* that the animals should be at absolute
rest, on account of the influence of muscular movements on the lymph-current.
From the lymphatics of the hind leg of a dog, under normal circumstances, a
scanty drop exudes about every ten minutes, and only with great difficulty can a
cubic centimetre be collected. But in inflammation a large quantity comes spon-
taneously, and by passive movements 20 to 30, or even 40 cubic centimetres, may
be obtained very quickly. The lymphatic glands become swollen and red, and
under the microscope were seen to be filled with fine oil-globules, when the in-
flammation was induced by the injection of emulsion. He considers whether the
increased quantity of lymph is due to an increase in the current, or to the pressure
of the exudation, and shows that the quantity of lymph begins to augment as soon
as the inflammation begins, or rather as soon as the irritative means have been
employed. Emminghaus showed that ligature of a vein was followed by rise in
the outflow of lymph, and that slackening the ligature was followed by a return to
the physiological condition ; so that a great uniformity exists, so far as concerns
the lymph-stream, whether the oedema is caused by inflammation or by obstruc-
tion. But the mechanism in the two cases must differ, for, as Arnold has shown,
the enormous increase of capillary pressure present in obstruction does not occur
in inflammation, and many characteristic differences between inflammatory and
obstructive oedema prove that in inflammation chemical and morphological con-
ditions affect the bloodvessels in quite a different way from the mechanical dam-
ming up of the circulation. If the sciatic nerve be cut, and the limb so ligatured
that the digital arteries still pulsate, in 24 hours the foot will become cedematous.
The lymph in this case is thin, slightly tinged red, imperfectly coagulating. The
cellular elements are almost exclusively red corpuscles, with a few white ones
almost lost amongst them ; the fibrin is almost at a minimum, and is less than the
normal percentage in dog's lymph. Inflammatory lymph, on the other hand, is a
yellowish, rather opalescent thick fluid, which coagulates as soon as discharged,
often within the canula, and contains only a few red, but a great quantity of white
corpuscles. The dried residue exceeds that of normal lymph noticeably, and that
of obstruction lymph many times. Section of the sciatic nerve remained without
any definite influence on the quality or quantity of inflammatory lymph. The
entire residue of inflammatory lymph was quite twice as much as that of obstruction
lymph ; but the difference of the ash was not so great. In experiments on the
head and neck, he found no very great difference in the lymph-stream on the
sound and the affected sides, and he infers that communications exist between the
two sides. The inflammatory lymph presented its characteristic conditions as well
before as after passage through the lymphatic glands. The concentration of the
fluid increased with the duration of the inflammation. Since A. Schmidt showed
the importance of the white blood-corpuscles in the formation of coagula, it has
been recognized that a plasma increases in coagulability in proportion to its rich-
ness in colourless elements. This held good of the inflammatory lymph, so that
in very diffuse inflammation it formed a lining of coagulum in the lymphatic
vessels themselves, which became stiff and inelastic. In gangrenous inflammation
the lymph-stream completely dried up. All the characters of the inflammatory
exudate, in his opinion, tell against Arnold's hypothesis of pre-existing stomata
in the walls of the vessels, or why do such different elements pass through in ob-
struction and in inflammation ? He remarks that it is possible to diagnose the
inflammatory or obstructive origin of an exuded fluid, provided the blood is not
268
Progress op the Medical Sciences.
[Jan.
hydraemic. Participation of the lymphatic glands in the inflammatory process
appears to be of slight influence on the lymph-stream. Electrical irritation of the
glands had no influence on the nature of the lymph-stream, except that it me-
chanically caused an outflow of their accumulated lymph. The whole of the dried
residue of the lymph in these experiments was preserved and the ash analyzed.
1000 parts of inflammatory lymph contained 137.67 parts of ash ; 1000 parts of
obstruction lymph contained 112.83 parts. The following table gives the results
of the analysis of 100 parts of the ash of each : —
Inflammation. Obstruction.
Chloride of sodium . . 76.086 . . . 74.429
Potassium .... 5.987 . . . 2.155
Sodium . . . . 3.214 . . . 3.574
The chloride of sodium appears constant in both kinds, but the potassium and
sodium appear to bear a relation to the concentration of the lymph. — London Med.
Record, August 15, 1877.
SURGERY.
On the Treatment of Ronula.
Dr. Panas (Bordeaux Medical, July 31) has frequently succeeded in curing
ranula by the injection into the tumour of from four to ten drops of a concentrated
solution of chloride of zinc. Among others, he cites one obstinate case in which
excision, seton, and drainage had successively failed ; the contents of the cyst
were always reproduced, and finally operative interference was abandoned, ex-
cept when attacks of suffocation rendered palliative puncture necessary. Ten
drops of a solution of chloride of zinc, of the strength of one to ten, were in-
jected without previous evacuation of the cyst ; and, shortly afterwards, the in-
jection was repeated with a 20 per cent, solution. In less than five weeks from
the time this treatment was begun, a complete cure had been produced. This
treatment is applicable to all varieties of mucous and serous cysts. It has suc-
ceeded in a case of subhyoid cyst, which had resisted cauterization and the injec-
tion of tincture of iodine ; it yielded to a single injection of chloride of zinc. —
London Med. Record, Xov. 15, 187 7.
Extirpation of the Larynx.
The possibility of removing with success a part or the whole of the larynx
seems to have been first hinted at by Koeberle in 1856. 1 In 1870 Czerny made
experimental observations on dogs, which proved that the operation could be
successfully done. These experiments were turned to account by Billroth, who
in 1873 performed the first excision of the human larynx. Operating for cancer
of the larynx, Billroth had the satisfaction of dismissing the patient two months
after the operation, cured, and able to speak clearly, though monotonously, by
means of the ingenious artificial larynx now known as Gussenbauer's tube.
After Billroth, various continental surgeons have performed excision of the
larynx for malignant growths ; and at present there are on record ten cases of
this operation. The following case is believed to be the first in which it has
been resorted to in Great Britain : —
In April, 1876, J. H., aged twenty-eight, consulted Dr. David Foulis. at
1 See Paul Berger in Hayem's Revue ties Sciences Medicates, t. ix., part i., p. 298.
1878.]
Surgrerv.
269
the Glasgow Throat Dispensary, on account of hoarseness. With the laryngo-
scope, a warty-looking growth could be clearly seen projecting under the anterior
end of the left yocal cord. The growth was of the size of a green pea : its colour
was a pale grayish-pink. The vocal cords and larynx otherwise were normal.
In phonation the cords closed over the growth, hiding it from view. On closer
examination, it was apparent that the growth was of a soft consistence, and that
it was sessile on a pretty broad base, the base being on the sloping under-surface
of the left vocal cord at its anterior end. The growth was removed by external
incision, and proved to be a papilloma.
In October, 1876, it was found that a nodule had reappeared on the old site,
and was growing steadily. On April 16, 1877, thyrotomy was performed; the
two halves of the larynx were held aside, and the growth was clipped out with
scissors, and its seat cauterized. In July the growth had again reappeared in
the old site, and a month later it was larger than ever before, filling nearly the
whole lumen of the air-tube. In reporting the case, Dr. Foulis says : "I felt
that it would not be right to attempt any mere excision of the growth in view of
the recurrence after the thorough removal and cauterization at the thyrotomy
operation. With this the patient was quite in accord ; and when I proposed to
him the removal of the larynx, he, after some hesitation, agreed to have it done,
chiefly because of the lingering death which was in prospect, and on the ground
that if an operation for the introduction of a tube into the trachea must be under-
taken in order to avert death by suffocation, it might be as well at the same time
to remove the diseased and useless larynx, and replace it by an artificial one.
On September 16 Dr. Foulis removed the larynx in the following manner :
•• My incision began at the lower edge of the hyoid bone, and ran down the mid-
dle line to about an inch below the cricoid cartilage. A small piece of lint was
applied to the fistula to prevent blood from entering the ah -passage. The soft
tissues were next dissected carefully off" from the laryngeal cartilages back to the
pharynx, first on one side and then on the other, and any small vessels which
bled were ligatured. There was not much bleeding, -and by simply waiting for
the oozing to stop a clear field was secured for the final stt-ps. The upper end of
the trachea was cleared, pulled forward with hooks, and divided at the first ring.
I incised lightly the mucous membrane at the back of the trachea transversely,
and introduced a leaden tube, curved like a siphon, with an India-rubber ring
round the end in the trachea, which it thus closely fitted. This curved tube
completely answered the purpose of preventing the escape of blood into the
trachea, and also of allowing respiration to proceed from a point which was away
from the field of operation. The cartilaginous box of the larynx was then pulled
forward with a sharp hook, and freed from its attachments at the upper end and
behind. I at first intended to leave the upper margin of the thyroid cartilage to
form an arch which might prevent the wound from collapsing and cicatrizing too
closely. But it was found that an extension of the growth had taken place
upwards along the scar of the thyrotomy operation, and this necessitated the re-
moval of the whole front part of the thyroid cartilage. The superior cornua of
this cartilage were left, as well as half of the arytenoid cartilages, these parts
being well out of the area of the disease. The edge of the trachea was fixed to
the skin on either side by two long wire sutures passed deeply into the tissues.
No other sutures or dressings were used. The ordinary tracheotomy tube, being
much too small to prevent fluids entering the trachea, I left in the leaden siphon-
tube for the first twelve hours. Thereafter larger tubes of gutta percha, and
finally of vulcanite, were procured, which, completely filling the trachea, pre-
vented anything but air from getting into it."
The operation lasted two hours and a half, and recovery took place uninter-
270
Progress of the Medical Sciences.
[Jan.
rupted by any serious accident. Five days after the operation the patient could
swallow liquids freely; a month later the wound had contracted to the size at
which it is desired to keep it, and a Gussenbauer's voice apparatus is being
moulded to it.
Examination of the parts removed showed that the tumour on the under sur-
face of the left vocal cord had not enlarged its base downward, but that it formed
a pendulous mass hanging into the trachea as far down as the first ring. It filled
the trachea in such a manner as to excite surprise at the possibility of tl e patient
breathing, hardly a chink remaining of the lumen of the air-tube. From the
upper part of the tumour an extension took place upwards, like a soft, pale,
grayish-red fringe, along the line of the thyrotomy incision. This part of the
growth had the structure of spindle-celled sarcoma.
The prognosis in this case is decidedly darkened by the fact of this extension
upwards having taken place. Of the ten cases in which the operation of excision
of the larynx has been performed, six cases are reported to have ended fatally.
Of these fatal cases two were due to the return of the disease at three and six
months respectively after the operation. Time alone can show whether my case
is to be ranked with these. Two more of the fatal cases succumbed to pneumonia
at four and fourteen days respectively after the operation. In another case gan-
grene of the lung carried off the patient at the fourth day. In the last of the
fatal cases the issue was due to collapse on the sixth day (from shock, insufficient
food, and imperfect protection of the trachea from introduction of blood and
secretions) . Of the remaining four cases of excision, one was a very partial
operation for stricture in syphilitic disease, the patient dying eleven months after-
wards from the constitutional affection. In two cases the reports are defective,
and the ultimate issue cannot be stated. Lastly, the ease published by Prof.
Bottini is the only one on record in which six months after total excision of the
larynx the patient was in a quite satisfactory state.
As to the steps of the operation, these must be of course determined in each
case by the nature of the disease. The simplest plan is that which I followed
before having had access to the accounts of the cases above noted. A single ver-
tical median incision from the hyoid bone to the second ring of the trachea ex-
poses the front of the larynx. The two sides of the cartilaginous box are then
freed from the muscles quite back to the gullet. Up to this point the larynx is
not opened, and no blood can escape into it. The larynx is then separated from
the trachea by a transverse cut, the trachea having been previously transfixed and
held forwards with a sharp hook. A large siphon tube of vulcanite, fitting the
trachea, is put in, to keep out the blood, and permit free respiration. If this is
neatly and carefully done, there is no need of preliminary tracheotomy and use of
Trendelenburg's tampon, which has the disadvantage of largely increasing the
length of the wound, while in Billroth' s case, at all events, it was not found to
facilitate matters to any extent. If there is much oozing of blood, something-
may be gained by adopting Rose's plan of lowering the head of the patient so
that the flow of blood is in the direction away from the trachea. The upper and
posterior attachments of the larynx are next cut, care being taken, in separating
the gullet and pharynx, to keep the edge of the knife close to the cartilages, so
as to avoid button-holing the gullet. It might be well to mop the raw surface
out with solution of chloride of zinc (thirty grains to the ounce) at the close of
the operation ; but it is not advisable to irrigate the wound in any way afterwards,
on account of the gulping and irritation which it sets up. Much may be done by
keeping the air of the room pure and disinfected. The tracheal tubes should be
as large as the trachea will admit, and are best made of hard polished vulcanite.
When oiled inside and outside with carbolized oil, they are easily changed, and
1878.]
Surgery.
271
remain clean for a considerable time. The last feature in the treatment is the
introduction of Gussenbauer's artificial vocal apparatus. This must be delayed,
however, until the wound is fairly healed and contracted, before which time the
apparatus is useless from its small size. — Lancet, Oct. 13, 1877.
Gastroraphy.
In the thirty-eighth number of the Wiener MediziniscJie Wochenschrift, 187 7,
Professor Billroth reports the further treatment in a case of external gastric
fistula, that had been previously described by Dr. A. Wolfler in the Archiv fur
Klinishclie Chirurgie, Bd. 20, page 577. This case was one of a gastric fistula,
involving the abdominal wall, in a female aged 25 years. The condition in ques-
tion had resulted from a chronic abscess over the lower ribs, which, after adhe-
sion of the stomach to the diaphragm and the anterior wall of the abdomen, had
perforated this viscus, and, at the same time, discharged its contents externally.
Professor Billroth at first closed the orifice, which was of the size of a silver
gulden piece, by a granulating flap. This was done with the expectation that the
flap would still resist the digestive action of the gastric juice, after the granulating
and vascular surface, directed towards the interior of the stomach, had, in course of
time, acquired an epithelial covering, and a cicatricial and consequently less vas-
cular condition. This expectation was based on the fact that one occasionally meets
with in the stomach as results of gastric ulcer, large cicatrices, ulcers which are de-
pressed below the surface of the mucous membrane, and contain much finer and
smaller vessels. This supposition, however, was not confirmed. About three
months after the operation the fistula opened again, and to the same extent as
previously, in consequence of digestion of the flap of skin by which its orifice had
been covered. At the period of her re-admission into the Vienna Hospital, the
patient was wearing a small plug, retained by a broad bandage. This closed the
orifice of the fistula very well, and prevented any flow of the contents of the
stomach whilst the patient was recumbent. It was found impossible, however, to
prevent a continuous discharge of gastric fluids while she was standing and at
work. The patient had lost flesh ; the margins of the external orifice of the
fistula were constantly inflamed and tender ; and the general condition had be-
come so intolerable, that there was an eager desire for some other attempt to bring-
about complete healing, even though this might be attended with some risk.
The first two attempts to bring about occlusion, or, at least, considerable con-
traction of the fistulous orifice, proved unsuccesssful. In one, it was sought to
produce obliteration by converting, through cauterization,, the mucous surfaces of
the fistula into a cone of cicatricial tissue. In the other, the mucous membrane
was separated from the muscular layer of the gastric wall at the seat of the fistula,
and this latter layer, together with the serous, was dissected away from the ab-
dominal wall for about the extent from the margin of the fistula, an attempt being
made during the cicatrization of the superficial parts to thrust inwards towards
the cavity of the stomach the detached flap of mucous membrane. The cause of
the failure in each of these proceedings is stated to have been the extensive adhe-
sion of the surface of the stomach to the anterior abdominal wall. In a third
operation the orifice of the fistula was covered by a large flap, taken from the
front of the thorax ; the lower margin of this flap being fixed by sutures to the
vivified lower margin of the orifice. This proceeding also failed, in consequence
of almost complete destruction of the flap, through the digestive action of the
gastric juice.
Professor Billroth finally performed the following operation for gastroraphy.
After the stomach had been thoroughly cleansed by repeated injections of water,
the adherent mucous and other coats of this viscus were, by means of the finger
272
Progress of the Medical Sciences.
[Jan.
and a raspatory, separated from the inner surface of the anterior wall of the abdo-
men. The adhesions were very extensive, and so firm as to necessitate for this
breaking down considerable force. After this proceeding, the stomach could be
drawn forwards to such an extent that it was possible, by means of fine silk
sutures passed through the serous and muscular coats, to bring the margins of the
abnormal gastric opening together. The orifice in the skin was then closed by a
single flap, taken from the healthy parts beloAv the fistula. The operation was
performed under the carbolic acid spray, and the normal flap and raw surface
were covered by Lister's dressings. During the first three days the patient was
allowed to take water only, and during the following eight days, only milk, in
quantities small at first, and gradual]}' increased. Subsequently to the com-
pletion of the operation, no food nor a single drop of fluid passed through the
fistula. The gastric wound healed speedily, and the skin-flap united almost by
primary intention. No particular phenomena were noticed. Six weeks after
the operation the patient was completely cured, and in a very good condition as
to general health and nutrition. — London Med. Record, Nov. 15, 1877.
Extirpation of Spleen for Rapid Hypertrophy.
Mr. H. L. Browne, Surgeon to the West Bromwich District Hospital, records
(Lancet, Sept. 1, 1877) the following case of extirpation of the spleen : —
Edmund W., aged twenty, brass finisher, was in good health until about six
months, when he began to get fat. A month after that had swelling of the leg
(left), which prevented him from working. He had to lay up in bed. The
swelling in the left leg went down, but the abdominal had increased, with more
or less variation, up to the present time. He had never suffered from fever or
ague ; had no history of injury to the side. Had been several voyages to Ame-
rica, and had not suffered from sea-sickness. No personal or family history of
syphilis. Now was in bed with great swelling of the abdomen. Both legs ana-
sarcous. Abdomen uniformly dull on percussion, with the exception of the right
flank, which was slightly resonant when he turned on his left side. Heart dis-
placed, the apex being level with the aortic valves ; its sounds weak but normal.
Breathing intensely laboured ; lungs apparently healthy ; haggard appearance ;
no albuminuria ; fluctuation very distinct through abdominal walls.
Under the use of purgatives and diuretics it was noted, five days later, that
the fluctuation was absent from the abdomen, which was found to be dull in any
position on the left side of the median line, and to have a less marked line of dul-
ness running irregularly down from the sternum to the pubes, two inches to the
right of the median line. The fingers could be passed from the right side under
the thin edge of a firm tumour, which was found to occupy most of the abdominal
cavity, and in which there was a large deep notch, marking it evidently as
splenic.
During the succeeding month the symptoms grew worse, and dulness extended
towards the right side. In one week the tumour grew two inches at its lower
borders, and the pain was intense.
The spleen was excised on February 23d. There were no adhesions, nor any
pedicle of a distinct kind. Four very large arteries were met with, one after the
other, as the spleen was slowly raised out of the abdomen ; these were secured
by double ligature before division, and also their veins. There was no hemor-
rhage. The lad rallied very well from the chloroform, but five hours afterwards
died suddenly. There was no hemorrhage after the operation. The tumour,
which was found to be a simple hypertrophy of the spleen, was eighteen and a
half pounds in weight.
As to the cause of the hypertrophy I can offer no remark ; it must be purely
1878.]
Surgery.
273
speculative. The lad had leucocythsemia. There were no other glandular affec-
tions. The youth of the patient, the almost certainty of a splenic tumour being
non-malignant, the absence of other disease, and the fact that the patient was
dying, and would have died in a few days, from the pressure alone on the blood-
vessels and viscera by the weight of the tumour — these are some of the strongest
reasons why the operation was, and should be, performed.
Two Peculiar Varieties of Hydrocele of the Cord.
Mr. Furneaux Jordan read, at a late meeting of the Boyal Medical and
Chirurgical Society [British Med. Journ., Oct. 13, 1877), an interesting paper
with the above title. He referred to the origin of hydroceles of the cord. He
considered them due to an imperfect obliteration of the peritoneal prolongation
which took place along the cord from the internal inguinal ring to a point a little
above the testis. This obliteration began at two points, at the ring and near the
testis ; and, if it were incomplete, fluid might collect in the unobliterated space,
forming a spherical enlargement, which was movable from the testis. Transpa-
rency was present, but was distinguished with difficulty, unless in the lithotomy
position. The disease was most frequent in early life, and was called " encysted
hydrocele of the cord," probably to distinguish it from the so-called " diffused"
variety. Of the two peculiar varieties now referred to, the first was a so-called
encysted hydrocele of the cord, connected with the abdominal cavity by a long
fine tube ; the second was an encysted hydrocele of the cord with a fine tubular
prolongation upwards, which ceased near the external ring, not connected with
the abdomen. The point of interest in the first case was the communication of
the hydrocele with the abdominal cavity by means of a fine tube of unobliterated
serous membrane ; in the second, the existence of a tubular prolongation running
upwards, but ending in a blind extremity outside the inguinal ring. In the first
case, a truss was applied : in the second case, acupuncture was resorted to, and
proved successful after two or three repetitions. The globular collection or fluid,
with the neck-like prolongation, suggested for it' the name of "water-bottle
hydrocele of the cord."
Treatment of Blennorrhagic Epididymitis with Iodoform Ointment.
Dr. Alvares, of Palma, in Majorca, has treated four cases of epididymitis
with iodoform ointment, and from his experience in those cases draws the follow-
ing conclusions : —
1 . Iodoform relieves the pain of blennorrhagic orchitis better than any other
application ; this result is obtained at the end of one or two hours.
2. Iodoform exerts a very manifest resolvent action, and has the advantage
over mercurial ointment, of causing no disturbance when absorbed.
3. The iodoform treatment shortens very appreciably the duration of the
orchitis, and prevents any consecutive induration of the organ.
4. The ointment used should contain, according to the intensity of the inflam-
mation, from one to two grammes of iodoform to thirty grammes of lard. — London
Med. Record, Nov. 15, 1877.
Carbolized Catgut Ligature.
At a late meeting of the Clinical Society of London (Lancet, Oct. 20, 1877),
Mr. Bryant exhibited specimens and drawings of arteries from four cases of
Ligature with Carbolized Catgut. The first preparation was from a man twenty-
nine years of age, who died from heart disease fourteen hours after ligature of the
external iliac for an aneurism of the right common femoral artery. The ligature
No. CXLIX Jan. 1878. * 18
274
Progress of the Medical Sciences.
[Jan.
used was of medium size, and no more force was employed than was necessary to
secure the vessel. At the autopsy the internal and middle coats of the vessel
were found to have been divided, whilst the external also was partly divided,
some clots being found both above and below, and the catgut intact. The second
preparation and drawing showed the right common carotid artery, to which a
ligature had been applied twelve days before death, in a man fifty-eight years of
age, for a supposed aneurism of the aorta and innominate artery. The operation
was performed on the 16th of January, 1877, with carbolized catgut. It was fol-
lowed by considerable relief of the pain, but the patient died from exhaustion on
January 28. The artery was found to have been completely divided as to all its
coats, and there was a firm clot both above and below the seat of ligature. The
ligature itself had entirely disappeared. The third preparation was from the
right subclavian artery of a man thirty-six years of age, who was admitted into
hospital suffering from a ruptured traumatic axillary aneurism. He died from
pulmonary complications on the thirteenth day from the operation. There was
no suppuration about the operation wound ; the subclavian artery and vein were
normal. A small firm clot existed for half an inch above and a similar distance
below the point of ligature. All the coats of the vessel were divided completely,
and only the knot of the ligature remained. The fourth specimen was from the
common femoral of a young woman, twenty-three years of age, in whom the
artery was ligatured for elephantiasis Arabum. She died on the nineteenth day
from the effects of gangrene of the leg. All the coats of the vessel were com-
pletely divided and repaired, there were good clots above and below the seat of
ligature, and a small knot was found attached to the artery. Thus, in all four
cases, the inner and middle coats of the artery were found to be divided, and in
one case the outer coat also. The complete division was, no doubt, the result of
secondary ulceration. In its primary effects, therefore, Mr. Bryant remarked,
the carbolized catgut ligature acted as an ordinary ligature, and caused also a
more or less complete secondary ulcerative action. He had ligatured ten other
large arteries in their continuity — five femoral, four external iliac, and one sub-
clavian. One case died on the tenth day. In one femoral the wound united
without any suppuration, and the patient did not know that any cutting operation
had been performed until he saw the scar on the seventh day, so slight was the
reaction. In none of the cases did he use the spray, but dressed with dry lint or
water dressing. One case died on the fourteenth day of pyaemia and heart dis-
ease. Secondary hemorrhage occurred in two cases ; in one of subclavian it was
slight, and the wound healed on the twenty-third day. In one out of four of
external iliac there was some slight secondary hemorrhage on the twenty-ninth
day. Whilst he could not agree with the views enunciated by Professor Lister as
to the mode of action of the catgut ligature, his conclusion was that it is the best
which we have at our disposal. — Mr. Callender inquired as to the date at
which the secondary hemorrhage occurred in the two cases mentioned. — Mr.
Bryant, in reply, stated that it was on the fourth and the twenty-ninth days
respectively. — Mr. Maunder observed that Mr. Lister advocated the use of car-
bolized silk nine or ten years ago, and he had used it with good results ; then he
substituted catgut. He himself had had nine cases of the operation with car-
bolized ligatures, only five with catgut. So far as his own experience had gone,
the use of the carbolized catgut had been attended with good results. One
femoral case healed with no suppuration, another suppurated freely. But the
experience of others had not been so satisfactory, and in some cases the results
had been disastrous. Such cases as those of Mr. T. Smith, Mr. Callender, and
others, and that of Mr. Spence, in which the catgut dissolved very speedily, led
him to the conclusion that the femoral should not be tied with the catgut. He
1878.]
Surgery.
275
himself would never use catgut again, seeing that it involved risks peculiar to
itself, and never associated with silk. — Mr. Barwell said that his experience,
derived from the ligature in five cases with catgut, led him to agree with Mr.
Bryant, for no accident had resulted in any case. It was a mistake to use too
much force in tying the ligature, and the> ends should not be cut too short. The
condition of the catgut was also of importance ; if left too long in the carbolized
oil it became brittle. He believed that the secondary hemorrhage in femoral
cases was from the vein and not from the artery. — Mr. Sydney Jones inquired
as to the age of the patient in whom the carotid was ligatured, and the condition
of the vessels. As to the time of absorption of carbolized catgut ligature, he
thought it was slow, for he had found that after tying small vessels with such
ligature in excision of the breast the sinuses remained long open. Mr. Bryant,
in reply, stated that the patient was twenty-nine years of age, and the arteries
very healthy. In one case the knot of the ligature was found adherent on the
nineteenth day, in the other on the fourteenth. He believed that the catgut
ligature divided the coats in the same way as any other ligature, whipcord or
silk, but that secondary ulceration did not necessarily occur, and this was an
advantage. He agreed with Mr. Barwell as to the importance of not drawing the
ligature too tight. — Mr. Callender stated that each of the cases in St. Bar-
tholomew's was a case of aneurism, in which the vessels were ligatured in their
continuity for the cure of the aneurism. In each of three cases the ligature ap-
peared to give way in a few hours, and pulsation recurred in the aneurism.
Aneurism of Aorta, Innominate, Subclavian, and Carotid Arteries successfully
treated by Double Distal Ligature.
At a meeting of the Royal Medical and Chirurgical Society held November
13, 1877 {Lancet, November 17, 1877), Mr. Richard Barwell reported the
following extremely interesting case in which aneurism was successfully treated
by ligation of the subclavian and carotid arteries. •
R. W , aged forty-five, was admitted into Charing-Cross Hospital under
the care of Dr. Pollock, July 24th, 1877, with a large aneurism at the right root
of the neck. The man has served both in India and the Crimea, and is now a
labourer in a foundry (the work requiring strenuous efforts). He has not had
syphilis ; the family history is remarkably healthy. In November, 1876, he had
vomiting and purging after a drinking bout, followed by rheumatoid pains in
shoulders and limbs ; these disappeared after a time, but not from the right arm.
He first noticed a swelling on the neck d unng March, 1877 5 his right arm became
weaker and was occasionally numb. The tumour is oval, just above the right
clavicle, it stretches from beneath the inner margin of the left nearly to the outer
margin of the right sterno-mastoid, and upward to the lower margin of the thyroid
cartilage; its projection is considerable, and its strong pulsation characteristically
expansile. Dulness prevails from the inner third of the clavicle over the first
intercostal space and second rib, and mingles with the cardiac dulness ; over this
space pulsation may be felt. The heart is displaced to the left, its apex beating
fully half an inch outside the nipple line ; strong epigastric pulsation would indi-
cate some cardiac displacement downward. The veins of the right side of the
neck and chest, and of the arm, are greatly distended. No bruit at the heart or
over the tumour, and there is no perceptible difference between the two radial
pulses. Dr. Pollock treated the case with rest, low diet, digitalis, and ice-bao-s
to the tumour, but the aneurism increased. Deligation was then proposed, but
the patient, after consideration, declined, and left the hospital. However, he
returned under Mr. Barwell's care on the 13th August, desiring to have the ope-
I
276 Progress of the Medical Sciences. [Jan.
ration performed. In the mean time the cervical tumour ha4v jnuch increased,
and was more prominent ; it measured horizontally between the limits of pulsa-
tion, by compass, 4^ inches, by tape just over 6 inches ; perpendicularly it extended
from the clavicle to above the middle of the thyroid cartilage, measuring by com-
pass 3 inches, by tape 3| inches ; the thoracic dulness and pulsation reached as
far as the middle of the clavicle ; the displacement of the heart seemed rather
greater; he had a cough, with very little laryngeal sound, and breathing and- cir-
culation were much embarrassed.
14th. The operation was performed first on the carotid. A peculiarity of a
greatly enlarged superior thyroid, simulating prolongation of the sac upward,
necessitated great caution until the source of the abnormal pulsation was revealed,
only just room enough being found to pass a ligature round the common carotid
between the aneurism and the bifurcation. The subclavian artery was then
reached with remarkably little bleeding, and a ligature passed round it, pressure
on the hollow of the needle obliterating the radial pulse. In disengaging the cat-
gut a vein above the brachial plexus, either the posterior scapular or a smaller but
distended vein, was ruptured ; its deep position, and the filling of the cup-like
wound with blood, rendered its ligation difficult and doubtful. Rather than
attempt this, Mr. Barwell did not wait to verify the isolation of the artery, but
knotted the catgut loosely, stuffed the wound firmly with antiseptic gauze, and let
the patient be carried to bed, the radial pulse still beating. The next day Mr.
Barwell removed the gauze, traced down the ligature, which included with the
artery a nerve of the plexus ; this loose ligature was left in place, and a fresh one
was passed and tied. These operations — carotid and subclavian — were performed
antiseptically. 2s o immediate change in the tumour was perceptible. Low
(milk) diet was ordered.
16 th. The breathing and circulation greatly relieved ; temperature normal. 23c?.
Cervical tumour harder ; transverse measurement by compass 3| inches, by tape
4f inches. Thoracic pulsation barely perceptible. 2dth. A very dry diet substi-
tuted. 2G(h. Slight pulsation, probably collateral, in radial. 2$th. Patient suffers
much from thirst. Heart-action excited; pulse 102; temperature irregular;
radial pulsation disappeared. 29th. Tumour measures by compass 3| inches, by
tape d{ inches.
Sept. 3d. The hospital Xo. 3 diet (fairly nutritious), and one pint of beer
daily. 5th. Temperature and pulse still high and irregular. Tumour harder ;
measurement by compass 3^ inches, by tape 4j inches. 8th. Compass 2f inches,
tape 3.£ inches. 9th. Compass 2\ inches, tape 2| inches. 10th. Compass 2^-
inches, tape 2^ inches.
On the 9th there was some arteritis of vessels in the arm ; on the same day the
temperature went down to 96°, and has since been normal. A like attack recurred
on the 23d of September.
Oct. 21st. Since the rapid diminution in the size of the tumour commenced,
the man has gone on uninterrupting well. A firm solid tumour lies behind the
sterno-clavicular joint, with pulsation communicated from the aorta; it feels about
the size of a cob-nut. Xo thoracic pulsation. Dulness extends about halt' an
inch outside manubrium sterni. The whole aneurism is consolidated.
Remarks (abbreviated) : The aneurism involved, without doubt, the aorta,
innominate, subclavian, and carotid, and was not far from bursting. The opera-
tion relieved immediately the oppression of circulation and breathing, showing
diminution of the thoracic, while the cervical part of the aneurism responded more
slowly. Mr. Barwell considers the system of diet produced a very coagulating
tendency in the blood. The whole of the subclavian is obliterated, as there is
still no radial pulse. The practical proof of -the theory, that aneurism of the in-
1878.]
Surgery.
277
nominate maybe treated by double distal ligature, has, as yet, been wanting (Mr.
Heath's well-known case' proved to be aortic only). Six such operations have
been performed. Of these, two proved fatal on the sixth day, one on the fifty-
fifth, one on the sixty-fifth day ; two, receiving no benefit, lived some weeks.
This case furnishes the practical proof that, not only innominate aneurism, but
aneurism of that vessel, and of aorta, subclavian, and carotid, are amenable to the
double distal ligature. Also, we may deduce from it, what Mr. Heath's case has
already proved, that aneurism of the first part of the aorta may be cured by this
operation.
In reply to certain questions Mr. Barwell pointed out that before the patient
came under his care he had already been subjected to rest and to medical treat-
ment, and he could not think that anything but surgical interference would have
saved the man's life. At the same time, he valued highly the treatment by diet
— too much neglected by surgeons — as an adjuvant to the production of that
coagulation in the sac which it was the object of the surgical operation to induce.
At the time of the operation he felt what appeared to be a bulging of the carotid
artery, and the height to which the tumour extended in the neck also pointed to
the carotid being involved. As to the present condition of the patient, he admitted
that there was a tumour which ought not to be there ; but he maintained it was
no larger than might be expected from the complete coagulation of the aneuris-
mal contents, and it would require a very careful examination to make out that
there was anything more now. The very great diminution in size of the tumour
could only be accounted for on the view of its complete consolidation. He hoped
to keep the case in view, and it was quite possible that, just as in Mr. Heath's
case, where the operation resulted in perfect cure, rupture might take place from
further extension of the aneurism at some later date. In Mr. Heath's case four
years elapsed between the date of operation and death. The only nervous symp-
toms following the ligature were a dull sensation and tingling in the arm, with
slight paresis, but these were transient. Xo sphygmographic tracings were taken.
The ligatures were cut short and left in the wound, and he must say that the
rapidity with which the wound healed and the rarity with which secondary hemor-
rhage followed were strong points in favour of the use of catgut. He tied the
ligature securely with a single knot, and did not cut it too close.
Ligature of the Common Carotid Artery in Cases of Injury of the External
Carotid.
In a memoir on this subject, abstracted in the Annali Universali di Medicina
(Parte Rivisla) for September, Dr. Giuseppe Ruggi gives the results of experi-
ments which he made on the dead body for the purpose of determining the best
operative proceedings to be followed in cases of injury of the external carotid
artery, and of ascertaining the course of the blood in the upper part of the carotid
after ligature and in its secondary branches. The conclusions at which the author
arrived are the following. 1. There are considerable anastomoses between the
carotids of one side and those of the other. 2. When the common carotid artery
is tied, these ana tomoses are capable of establishing a supplementary retrograde
current in the course of a few minutes or seconds. 3. The current from one ex-
ternal carotid to the other is slow, in consequence of having to pass through a
very fine network composed of the ultimate ramifications of the vessels of the
two sides. 4. As regards the internal carotid, the current which takes place
through the circle of Willis is three or four times as 'strong as that in the external
carotid.
Lancet, Jan. 5, 1867, p. 12, and July 3, 1870, p. 11.
278
Progress of the Medical Sciences.
[Jan.
Collating these results of experiment with those of clinical observation, Dr.
Ruggi agrees with Velpeau that, in most cases, ligature of the external carotid
is not sufficient to restrain hemorrhage from injury of one of the branches of the
external or internal carotid, while the application of a ligature to one or the other
of the secondary carotids absolutely interrupts all secondary circulation. He re-
lates the following case in support of this view.
A man was admitted into hospital with neuralgia of the left inferior dental
nerve, for which excision of a portion of the nerve was performed. Ten davs
after the operation, the patient had repeated and abundant hemorrhage from the
mouth. The source of the bleeding could not be accurately determined, but was
supposed to be a rupture of the inferior maxillary artery, produced by ulceration
in the course of the operation- wound. The right side of the face was enormously
swollen and pale, the pulse was small and intermittent, the limbs were cold, the
voice was feeble. Dr. Ruggi tied the common carotid artery 2^ centimetres
(about an inch) from its origin : he also placed a ligature on the superior thyroid.
The hemorrhage did not return. Along the course of the left external maxillary
and superficial temporal, all pulsation was absent. The patient left the hospital
perfectly cured. — London Med. Record, Nov. 15, 187 7.
Diagnostic Value of Pulsation, a propos of a Case of Pulsating Tumour of the
Upper End of the Left Tibia.
In the Commentario Clinico di Pisa for May and June, 1877, Professor
Pasquale Landi, of that city, analyzes the six cases collected by Xelaton, and
considered by that surgeon entitled to the name "true aneurism of bone," four
other cases collected by Yolkmann, and related in Pitha and Billroth's Hand-
book; a case of Cappelletti's (Trieste) ; and, lastly, one of Landi's own, making
twelve in all.
The tibia was the bone affected in nine cases, in eight of which the head of the
bone was the seat of the tumour, while in the ninth (Scarpa's) this was below
the head. The lower end of the femur in two cases, and the head of the humerus
in one (Richet's), completed the list. Except two, the cases ran a slow course ;
in one half an injury is related, and in the other half is wanting.
All .these intra-osseous tumours pulsated, except Richet's, where, however, a
blowing murmur was audible. In one other only (that of Carnochan, lower end
of the femur) was there a bruit.
In nine the tumour grew before the thirtieth year, and in two at the fifty-fourth
and sixty- third; while in one no age is given. All resembled ordinary aneurism,
in the feature of distensile pulsation (in the one case replaced by a murmur, with
which it was combined in another), and in the cases of Pearson and Scarpa were
actually diagnosed as aneurism of the anterior tibial ; but the anatomical exami-
nation failed in every case to show the artery implicated. They were all, more-
over, clinically different from ordinary aneurism in the characteristic feature of a
bony wall, more or less imperfect, no doubt, but present in each. In two only
did complete cure result from ligature of the main arterial trunk (case of Lalle-
mand and that of Roux). In two others, after ligature of the main artery, the
tumour ceased to pulsate, but remained diminished in one case (that of Largout
and Fleury) and fluid in the other (Nelaton's).
In three cases the ligature failed, and recurrence took place (Dupuytren,
Carnochan, Cappelletti) ; but the consequent amputation was successful. Pri-
mary amputation succeeded in two (Parisot and Scarpa), but fatal recurrence
took place after five years in the case of Scarpa. Two primary amputations were
fatal (Pearson's and Richet's).
1878.]
Surgery.
279
He discusses at great length the clinical signs, the results of treatment, and the
pathological anatomy of this very rare class of cases, more especially in relation
to their origin in a new growth, such as myeloid, or in some cases a malignant
central osteo-sarcoma ; and offers the opinion "that osteo- aneurism does not
really exist, and that certain symptoms, characteristic of ordinary aneurism, are
but accessory phenomena in the case of certain new growths of a nature more or
less malignant."
His own case he diagnosed to be pulsating myeloid tumour of the head of the
tibia, and microscopical examination confirmed the opinion. Amputation proved
successful. The four cases of Professor Gherini are then briefly given. (1)
Pulsating tumour of innominate bone, mistaken for abscess and punctured, but
bleeding arrested. Ultimate death from exhaustion, the tumour spreading
greatly. No examination. (2) Myeloid pulsating tumour of patella. (3)
Pulsating tumour of lower end of femur. (4) Pulsating tumour of head of tibia.
Thus in only one of these was the exact nature of the growth made out, but cases
3 and 4 are judged by Professor Gherini, from their resemblance to case (2), to
be probably of the same nature. — London Med. Record, Nov. 15, 1877.
Sarcoma of the Median Nerve; Resection without Disturbance of Sensation.
Kraussold relates in the Archiv fur Klinische Chirurgie, Band xxi., the
case of a boy aged five and a half, who, in consequence of severe and painful
pressure with the hand ten months before, had a tumour of the upper arm. It
had gradually developed, and was about as large as a hen's egg, lying in the
right internal bicipital furrow, and reaching from the epicondyle to the upper
third of the arm ; there was distinct fluctuation. There were no disturbances of
motion or of sensation in the forearm and hand. The swelling being supposed to
be an abscess, an incision was made, when it was found that it was a sarcoma,
the interior of which had become disintegrated ; it was encapsuled, but, becoming
spindle-shaped above and below, was found to be continuous with a thick cord
which was recognized by its position as the median nerve. In extirpating the
tumour, nearly eleven centimetres (about 4.3 inches) of the median nerve were
removed. Some hours after the operation, the only disturbance of motion that
could be detected was inability to bend by voluntary action the index finger and
thumb ; all the other motions of the fingers, hand, and forearm, as well as the
sensibility of the limb, especially in the region of distribution of the median
nerve, were normal. These conditions remained after the healing of the wound.
The tumour was a small-celled sarcoma ; a few changed nerve-fibrils were scat-
tered within it, while others lay in its capsule. After recounting the symptoms
expected to follow division of the median nerve, Kraussold comes to the conclu-
sion that the absence of most of them in the present case may be explained in
one of two ways : either by a pre-existing anomaly or by the numerous nervous
anastomoses. The first supposition is rendered improbable by the fact that the
divided median nerve was of normal thickness. The second assumption has
more in its favour ; the long duration and gradual development of the disease
may have given time for a further formation of anastomoses. This case indicates'
the necessity for a very careful criticism of the descriptions of the remarkable
results of suture of nerves, and of regeneration of nerves and restoration of their
functions after division. — Brit. Med. Jo urn., Nov. 3, 1877,
280
Progress of the Medical Sciences.
[Jan.
OPHTHALMOLOGY AND OTOLOGY.
Sclerotomy in Glaucoma.
Professor L. Mauthxer, of Vienna (in the Wiener Medizin. WochenscJirift
for July, 187 7) has a long communication on the advantage of sclerotomy in
glaucoma over iridectomy. In the year 1869, Berlin, at the Heidelberg Ophthal-
mologic al Congress, remarked that, in certain cases of chronic glaucoma, very
rapid loss of vision follows the latter operation, without any hemorrhage having
occurred; and he attributed these cases to the supervention of atrophy of the
optic nerve as the result of the iridectomy. Liebreich answered to this, that the
swelling (Erblassen) of the papilla after iridectomy is a constant symptom, and
could not be regarded as the commencement of atrophy. Dr. Mauthner has no
doubt that cases frequently occur in which vision is lost after iridectomy, where
there is absolutely no visible cause to account for the unfortunate circumstance.
These facts are mentioned in disparagement of Von Grafe's operation, and as a
reason why it is desirable to give sclerotomy a fair trial ; but the real reasons
given for the adoption of sclerotomy in glaucoma are, that the author has found
many cases in which the large opening in the iris after iridectomy interferes se-
riously with the function of the eye, and that he finds the removal of a segment
of the iris to be quite an unnecessary proceeding. He states that, in cases in
which the segment of the iris has been incompletely removed, the tension has
been reduced as well as in those in which no such failure has occurred ; and that,
when sclerotomy has been performed in the manner in which he describes the
operation, the results have been more successful than those after Von Grafe's
operation.
The operation of sclerotomy described by Dr. Mauthner consists in the division
of the sclerotic in front of the iris, and he gives the following directions: —
Before the operation, a drop of a one per cent, solution of the sulphate of
eserine is to be applied, when the pupil will undergo contraction, unless there be
atrophy of the iris. If there be atrophy, he remarks that it is exceedingly diffi-
cult to avoid prolapse. In adults the operation should be performed without
anaesthetics. The division of the sclerotic should be performed upwards, in case
it is necessary to perform iridectomy. On account of accidental prolapse of the
iris, this is the most favourable position to do so. A Von Grafe's cataract-knife
is now to be entered a millimetre behind the edge of the cornea, and carried
through as if to form a scleral flap by Wecker's method. After transfixion, the
operation is completed by causing the knife to cut its way out very slowly, so
that the aqueous humour may escape very gradually ; it is in this manner that
the prolapse of the iris is prevented ; the flap is not, however, to be completed,
but a small bridge is to be left at its upper part.
The author considers that the essential part of the operation of iridectomy is
the division of the sclerotic at the margin of the cornea, and that the success of
the operation depends on the extent of. the sclerotic divided ; he thinks, there-
fore, that the above operation is more certain than iridectomy, as the extent of
the scleral wound is greater.
The knife should not be withdrawn from the eye until just as the last of the
aqueous humour has escaped ; as it is withdrawn, its flat side is very gently
pressed upon the iris. A drop of the solution of eserine is then applied, and the
eye is dressed with the usual pad and bandage.
The dressing is to be renewed after a few hours, and another drop of the solu-
tion of eserine applied. The patient should be kept in bed for forty-eight hours.
If the iris prolapse, it may either be returned by gentle manipulation with a
1878.]
Ophthalmology and Otology.
281
curette, or the operation of iridectomy may be completed. The author recom-
mends the latter proceeding only when the prolapse is considerable, but remarks
that even in this case he lias seen very good results from its return.
Dr. Mauthner also hopes for good results from the performance of the operation
in hydrophthalmus. He records a case in which he performed the operation with
apparent success ; but the time after the operation, apparently only a few weeks,
was not sufficient to enable him to assert that it was successful, except in its
immediate results. — London Med. Record, Oct. 15, 1877.
Drainage of the Eye in Cases of Detached Retina.
Deutsche Zeitschrifi f. prakt. Med. of August 18th publishes an abstract of a
paper read by Dr. Hermann Cohn on this subject before the Silesische Gesell-
sehaft f iir Vaterlandische Cultur. He remarked that detachment of the retina,
especially in cases of high myopia, has hitherto been regarded as one of the most
incurable diseases of the eye. Amongst 20,000 cases of ophthalmic disease that
had fallen under his notice in the course of ten years, there had been 191, or
about one per cent., of cases of separation of the retina. Sichel, Kittel, and Arlt
endeavoured to effect a cure in such cases by the introduction of a needle through
the sclerotic. Graefe not only punctured the sclerotic, but divided the retina,
with the object of allowing a communication to be established between the fluid
subjacent to the retina and the vitreous. This proceeding, though occasionally
brilliantly successful, was, however, found to be not unattended with danger ot
cyclitis and inflammation of the vitreous, and it fell into discredit. Cohnheim,
Lasinsky, and Samelson have observed cases where a cure resulted from the em-
ployment of internal means, by pressure and by confinement in a dark chamber.
Such a result, however, is exceptional. About six months ago Wecker suggested
the trial of drainage of the eye by means of the introduction of a loop of gold
thread through the sclerotic and under the detached retina. He applied this
method in twenty-six cases, but has not published them. Cohnheim has tried it
only in four cases, the myopia varying from ten to twelve dioptrics, and has, in
all instances, obtained excellent results. The gold wire should be very fine. In
the course of these experiments Cohnheim has satisfied himself that the human
eye can carry for months a gold wire of one-third of an inch in length, without
the slightest reaction being excited or influence felt. Detachment of the retina
may, by this means, be immediately prevented from continuing, even after it has
been of three years' duration. The retina, as soon as it has become reapplied,
becomes again immediately capable of perception, even after the lapse of three
years, so that the field of vision recovers its normal extent. He goes on to say-
that only the sense of space returns, but not the perception of colour. Blue-blind
and green-blind eyes at the time of detachment remain blue-blind and green-blind.
After some time a separation is discernible, but it is flatter, more rugose, and no
longer vesicular ; and this, by slight movements of the gold drain can again be
diminished. Cohnheim finally thinks the proceeding of drainage of the eye espe-
cially adapted for cases of subretinal cysticerci. In no instance was any inflam-
mation of the eye or impairment of the pre-existing amount of vision observed.
It has also the advantage that it does not interfere with general methods of treat-
ment.— Lancet, Sept. 1, 187 7.
On Acute Cellulitis of the Oruit.
Dr. Sonnenburg, of Strasburg, in an article {ZeiUchrift fur Chirurgie, Bd.
vii., Heft. 5, 6, 1877), on acute cellulitis of the orbit, states that this is not an
affection of frequent occurrence, although it might be assumed that the orbitar
282
Progress of the Medical Sciences.
[Jan.
cavity, from the abundance of fat and cellular tissue contained therein, and from
its richness in vessels and nerves, would present very favourable conditions for
the origin and development of phlegmonous inflammation. The cases that have
been recorded in surgical literature show that acute orbitar cellulitis may be due
to one or other of very many causes. In some instances the affection occurred in
the course of an infectious disease, as typhus, variola, scarlatina ; it has not unfre-
quently been observed as a complication of suppurative meningitis, and has occa-
sionally coexisted with or followed facial erysipelas. Traumatism, surgical a? well
as accidental, has, in many cases, given rise to this form of inflammation. In-
stances have been recorded of orbitar cellulitis consequent on operations for squint
and on enucleation of the eyeball. The prolonged presence of a foreign body in
the orbit, periostitis or necrosis of some portion of the walls of the cavity, and in-
flammation of the lachrymal gland, have been recorded as occasional antecedents
of the orbitar cellulitis. In two cases of rapid and destructive phlegmon of the
orbit recorded by the author of this contribution no cause for the affection could
be discovered. Acute orbitar cellulitis may occur at any period of life, but has
been most frequently met with in young and middle-aged subjects. The most
favourable seasons seem to be the spring and the autumn. This affection of the
contents of the orbit has, according to the author, well-marked clinical characters,
and may in most instances be readily diagnosed. From the facts that the inflamed
tissues are inclosed on all sides but one within unyielding osseous walls, and that
they are mixed up with many bloodvessels and nerves, the symptoms of acute-
orbitar cellulitis are, as may be imagined, very severe, and the pain intolerable.
The inflammation is usually preceded by rigors, general uneasiness, and fever.
The more prominent symptoms during the attack are, intense pain in the orbit,
exophthalmy, swelling and congestion of the eyelids, oedema of the conjunctiva,
especially of tarsal folds, which extend to and overlap the margins of the cornea.
The movements of the eyeball are usually abolished in consequence of participa-
tion of the recti muscles in the inflammatory action. If proper care be taken in
establishing the diagnosis, acute cellulitis of the orbit ought to be distinguished
without difficulty from any other affection of this region. In general inflamma-
tion of the eye exophthalmy is due to distension and enlargement of the globe
itself, whilst in cases of genuine inflammation of the adipose tissue of the orbit
there is simple dislocation of the eyeball forwards. From acute inflammation of
the lachrymal gland, cellulitis of the orbit may be distinguished by the acuity of
its process, by the severe pain attending it, and by the position of the eyeball,
which is dislocated directly forwards, and is not, as in cases of the former affec-
tion, forced downwards and inwards. In periostitis of a portion of the orbital wall
the margin of the orbit is generally tender on pressure, the skin and subcutaneous
connective tissue of the eyelids and cheek are not so readily and so speedily in-
volved, consecutive inflammation of the orbital fat is generally localized, and the
eyeball is dislocated laterally rather than in a forward direction.
In the opinion of Dr. Sonnenburg the phenomena and symptoms attending
genuine phlegmon of the orbit indicate that this affection is an infective inflamma-
tion. He holds that in those cases where no other cause is to be made out, the
orbitar inflammation is connected with inflammatory processes in the deeper parts
of the face, as the pharyngeal and nasal cavities. This infective phlegmon is at-
tended with such severe local phenomena, in consequence of the special condi-
tions— pain, pressure symptoms, swelling, and fever — being intensified to the
highest degree by the unyielding nature of the walls of the orbit and by the abun-
dance of vessels and nerves coursing its cavity. The occurrence of consecutive
meningitis is not so frequent as one might be led to anticipate by a knowledge of
the free communication of the lymph spaces of the orbit with those of the cranial
1878.]
Ophthalmology and Otology.
283
cavity. Facial erysipelas is a much more frequent complication. In orbitar
phlegmon the eye is generally in much danger. In the two cases reported by Dr.
Sonnenburg the functions of this organ were speedily destroyed. There was con-
siderable retinal extravasation of blood in one case, and ulceration with opacity of
the cornea in the other. In many cases vision is destroyed through neuritis optici ;
sometimes, though less frequently, through detachment of the retina, or through
suppurative irido-choroiditis. Orbitar phlegmon terminates most . frequently in
suppuration, and often in necrosis of the soft tissues of the cavity. The most
important details of treatment are deep incisions and the application of moist
warmth. — British and Foreign Med.-Chir. Review, July, 1877.
On the Treatment of Suppurative Otitis by Drainage of the External Auditory
Meatus.
In the Annates des Maladies de V Oreille et du Larynx, for December 31, 1876,
is an article by Dr. Guyon, of the Neckar Hospital, on the above subject. He
says that drainage of the external auditory meatus has enabled him to obtain, in
two different cases, very good effects. The surgical means to which attention is
drawn is one of the most simple, its application is easy, and its aim well defined.
Its object is to insure by the aid of a drain a free and continual discharge of the
pus secreted in or poured into the external meatus. This free and easy discharge
rapidly relieves pain. The paroxysms lose their intensity and soon disappear,
and the progress of the disease is very favourably influenced. The normal dis-
position of the external meatus lends itself badly to this free and continued dis-
charge, necessary for the regular cure of any suppurating cavity. It is scarcely
necessary to recall to mind the curved direction of its walls, and its narrowing at
the point of junction of the osseous and cartilaginous portions, its size being in
fact greater at the extremities than in the middle. It is thus easy to see that pus
must accumulate in the deeper part of the auditory canal, and that it may, by
accumulating, cause pain, and maintain by its imperfect evacuation the lesions
which have caused its secretion. The auditory canal follows in this respect the
pathological law which governs all suppurating cavities.
The first occasion on which the author applied drainage to the auditory meatus
was in October last. He was called in by a confrere to a member of his own
family, with the idea that he might be able to do something to alleviate the pain-
ful paroxysms which had existed for some days, by incising an abscess of the
meatus, to the existence of which the pain was attributed.
The inferior wall of the meatus was found swollen and red ; but though there
was undoubtedly a phlegmonous condition, there was no evidence at any point
accessible to a bistoury of any collection of pus. It was stated, however, that pus
had previously flowed abundantly, and had recurred several times, and that this
appeared to determine the paroxysms. v
The author considered that the painful symptoms were due to the retention of
pus, but he had never used drainage in a similar case, nor did he know any in-
stance of such a practice. It was inoffensive, however, and was too much in
accordance with the tastes of the patient, who strongly objected to the bistoury,
not to be proposed. " I took then a piece of drainage-tube, of medium size, and
plunged it into the auditory meatus, taking care not to press it against the mem-
bran a tympana, and to let it hang out a sufficient distance into the concha.
' ' There was no immediate discharge of pus, this being one of the periods of
remission. The effect of this mode of treatment was, nevertheless, very happy.
From the time of the application of the drain there was no paroxysm, and fifteen
days afterwards the patient came to tell me of the excellent result obtained. The
drain was cleaned and replaced daily, and the patient, recognizing its value, had
not yet ventured to do without it completely.
284 Progress of the Medical Sciences. [Jan.
This first case was one of external otitis ; the second, which occurred in the
practice at the Neckar Hospital, was one of otitis of the middle ear. The patient,
a month before admission, had had a simple quinsy, followed by pains in the ear.
On admission, he presented all the signs of suppurative otitis media, with perfo-
ration of the membrane and invasion of the mastoid cells. The mastoid region
was the seat of a very characteristic oedematous swelling, and the tympanic pro-
jection was evident. The pain was more severe at night than by day, rest in bed
impossible, and mastication painful.
" I immediately applied a drain of middle size, about three centimetres long.
The results of this mode of treatment, combined with poultices, were more com-
plete than I ventured to hope. The pain rapidly lessened, and was only very
slight on the next day but one after the application. At the same time, the
oedematous swelling of the mastoid region diminished and had disappeared by the
fifth day ; and although the patient is still under treatment, and always continues
his drainage-tube, his local state is sufficiently satisfactory to be considered as
certain of cure." — London Med. Record, June 15, 1877.
MIDWIFERY AND GYNECOLOGY.
On the Investigation of the interior of the Uterus by the Carbolized Hand at long
Intervals after Delivery.
Dr. J. Matthews Duncan, Obstetric Physician 1o St. Bartholomew's Hos-
pital, reports {Brit. Med. Journ., Oct. 27, 1877) the following case.
Mrs. A. B. was confined at her home in the south of Scotland on June 5th,
1876. The child born was her second. She was attended by her physician, who
lived in her neighbourhood, and to him I owe most of the details now to be given
of her case. The labour was easy, natural, and lasted four hours. The placenta
was removed without difficulty about fifteen minutes after the birth of the child.
The membranes were twisted to insure their complete withdra wal, and then a
dose of ergot was administered. At 9 A. M. all was completed and well. In
the evening of the 6th, Mrs. A. B. had a feeling of cold in the back and severe
lumbar pain. On the morning of the 7th, her pulse was 120, and at night it was
140, at which rate it continued till after my visit on the 8th. The temperature
rose correspondingly. I saw the patient on the afternoon of the 8th, eighty
hours, or nearly three days and a half, after her confinement. I found her with
every appearance of having an attack of pya?mia or puerperal fever postpartum.
The abdomen was slightly tympanitic, the uterus somewhat tender.
The circumstances of the case, both intrinsic and extrinsic, rendered the crisis
extremely alarming and important. The lochial discharge was natural, and
reported as having no fetor. Nevertheless, I made a vaginal examination, push-
ing the finger into the cervix uteri, and hooking away shreds of clot, which were
unexpectedly found to be distinctly putrid. A second attempt brought away a
small bit of membrane, putrid. Being at a great distance from proper instru-
ments to complete what I regarded as the desirable treatment — namely, the
removal by forceps of any other pieces of membrane or decidua — and time being
very valuable, I had chloroform administered, with a view to the introduction of
my hand into the vagina and of my fingers into the uterus, to effect the explora-
tion and removal of what might be found that should be taken away. Doing
this I gradually penetrated further and further into the uterus without finding
anything. At last my whole hand was inside the organ, which felt not unlike an
J 878.]
Midwifery and Gynaecology.
285
uterus only recently evacuated. In the fundus of the uterus, it was now my
extreme good fortune to find adherent an irregular lacerated patch of chorionic
membrane, about four inches long and an inch broad. It was found to be fetid.
After this, I left the patient. Both pulse and temperature fell in a marked manner
after this operation. The alarming appearance and symptoms disappeared. The
pulse remained high for several days ; but the extreme anxiety of the physician
and friends was subdued for good. The fetor of the discharge was recognized by
the nurse after my visit, but only at first, or for less than a clay.
While, as is well known, there is often insuperable difficulty in classifying cases
of so-called puerperal fever under the heads pyaemia, septicaemia, ichorasmia,
there can in this instance be no hesitation in designating the disease as simple sep-
ticemia. Such cases are familiar to the gynaecologist. A decomposing uterine
fibroid, a decomposing blood-clot in a hamiatocele, produce shiverings, sweatings,
vomiting, delirium, high pulse, high temperature : a most alarming combination
of symptoms, which, on the removal of their cause, is dissipated with extraordi-
nary rapidity, in a few hours, as if by a charm. Such was the fortunate course
of events in the case just narrated ; but, had the putrefying membrane continued
much longer in a puerperal uterus, a fatal result was probable.
In the case which I have narrated, the greatest care and attention did not secure
the complete withdrawal of the membranes. The position of the persistently
remaining shred renders it unlikely that any forceps would have reached it and re-
moved it entirely ; nor is it probable that it would have come away in the discharges
early enough to allow of the preservation of life, already most seriously threatened.
It is under these circumstances that I propose the new operation of investigating
the interior of the uterus by the carefully carbolized hand of the accoucheur, with
a view to finding and removing decomposing substance. In such a state of matters,
I have hitherto used the practice of Baudelocque ;J namely, antiseptic intra-ute-
rine injections. I employ a double catheter, and I have repeatedly had reason
to be satisfied with the results. But, in the cases where I have used this treat-
ment successfully, there has not been washed out by the injections any shred of
hidden membrane ; and I very much doubt whether injections in the case which
I have narrated, would have produced this supreme result ; for, besides the
difficulty of directing the current so as to envelop and remove the adherent
membrane, there is the absence of any knowledge where the hidden membrane
is — absence, perhaps, even of suspicion of its presence.
There is, of course, as yet, no properly formed professional opinion as to the
length of time after delivery during which it is j>ossible to introduce the whole
hand into the uterus in a natural case ; and it is the whole hand that has to be
introduced with a view to doing completely the operation I propose. The nearest-
approach to conditions similar to those of my case is found in instances of reten-
tion of the placenta. Active interference in this morbid condition implies intro-
duction of fingers, and often of the whole hand ; and the difficulty feared is con-
traction of the internal os uteri or higher up.
Tlie Septic Influence of Locliial Discharge.
In a treatise published at Giessen, Prof. Kehrer describes a series of experi-
ments undertaken in order to ascertain the poisonous influence of normal and
abnormal lochia! fluids at different periods after parturition. The lochial fluid
was taken daily for from five to seven days after delivery, and its effect was tried
in two different ways ; first, by injection under the skin of rabbits, and secondly
by inoculation of the parturient women themselves. The author arrived at the
1 System of Midwifery, Heath's translation, vol. ii. p. 25.
286
Progress of the Medical Sciences.
[Jan.
following results : In all cases, even when the course of the puerperal state was
perfectly normal, the lochial fluid injected into rabbits produced extensive inflam-
mation and suppuration in the cellular tissue at and around the point of injection.
In many cases the lochial fluid, even of the first day, produced diffuse phlegmo-
nous inflammation, in others this was only produced by the lochia of the second
or third day. The intensity of the effect increased in proportion to the time
which had elapsed since delivery, within the limit of the period of observation ;
but it was not ascertained precisely when the maximum was reached, or when
the poisonous quality had disappeared. The author concluded, however, that
this would be the case when the discharge had become purely mucous. The
later lochia of healthy puerperal women produced abscesses similar to those
caused by putrid lochia in the earliest days. The constitutional disturbance as-
sociated with the abscesses increased in a similar ratio, in proportion to the date
of the lochia. The diurnal temperature of the animals experimented upon showed
a certain resemblance to that of the puerperal women in whom the lochia' were
putrid. The blood which flowed from the genitals immediately after delivery
proved to be comparatively harmless when injected subcutaneously. One excep-
tion, however, to this rule occurred, a case in which a slough was formed at the
point of injection, and the cellular tissue beneath became infiltrated with pus.
The author considered, however, that this might have arisen from some want of
care in filtering the blood or making the injection.
The result of experiments by inoculation upon the puerperal women themselves
was that the lochial fluid of the first and second day produced scarcelv any reac-
tion, only in some cases a slight appearance of inflammation. That of the third
and later days, however, produced decided inflammation, but only of a slight and
limited character, if taken from a healthy puerperal woman. The results of
inoculation thus differed somewhat from those of subcutaneous injections in rab-
bits, in which normal lochia of the later days produced as acute an inflammation
as putrid lochia. In cases where any puerperal disorder occurred, the inocula-
tion produced a higher degree of inflammation, and this occurred, not only with
putrid lochial fluid, but with that which, to the senses, did not a])] tear other than
normal, a fact which has great importance in reference to the etiology and pro-
phylaxis of puerperal septicaemia. The first marked rise of temperature did not
coincide in time with the appearance of this poisonous quality in the discharge,
but in some cases occurred earlier, and in some later. — Obstetrical Journal of
Great Britain , Nov. 1877, from Archiv far Gyitizkologie, B. xi. H. 2.
Mammary Abscess treated Antiseptically.
Dr. James Carmichael reports (Edinburgh Med. Journal, Oct. 1877) the
following case where the antiseptic method of treatment contrasted most favour-
ably with the old: —
Mrs. B., multipara, of somewhat delicate constitution, fell in labour on the
loth of November. I saw her about six hours after. On examination, the
breech presented at the outlet. During the interval between the pains, the feet
were brought down, and delivery was easily effected. All went on well till the
third day, when the breasts became gorged, and she had an attack of ephemeral
fever, which passed off in a few hours in the usual way. The child took the
breast lazily, and both nipples became sore. Glycerine of tannin was applied,
and the child allowed to take the breast only through a shielded teat. The pa-
tient continued to recover slowly, and was able to be up on the eleventh day.
The nipples, however, were still troublesome, but otherwise she appeared well.
On the fifteenth day the right breast was painful, and a hardness could be felt in
the submammary tissue fixing the breast to the pectoralis muscle. The swelling
1878.]
Midwifery and Gynecology.
287
continued to increase, and the inflammation rapidly spead throughout the mamma.
On the seventeenth day fluctuation became quite distinct, and I accordingly
made an incision two inches in length, at the most depending part of the abscess,
in a line radiating from the nipple to the circumference of the breast. About
twelve ounces of thick creamy pus were, evacuated, poultices applied for twenty-
four hours, and subsequently water- dressing. A considerable quantity of matter
continued to be discharged for some time, and three weeks elapsed before the
wound healed.
Four days after the abscess in this the right breast was opened, the patient
beiran to complain of the left breast, and on examination it was found to be tumid
and swollen, but painless. Belladonna ointment was applied with gentle friction.
Diluted tincture of iodine was likewise used, but without effect. At the end of
ten davs the breast had become enlarged and prominent, and fluctuation was dis-
tinct over its entire extent, giving the impression that the whole mamma was
converted into one large abscess.
The patient was now very weak, and the excessive discharge from the other
breast, no doubt, assisting in the production of this condition, it became a matter
of some moment to save her, if possible, a repetition of the same debilitating
process a second time. I therefore determined to operate on this occasion anti-
septically.
Having placed a rag soaked with carbolic oil over the breast, I raised its edge
and made an incision about an inch long, quickly replacing the rag. With both
hands applied, I gently squeezed out the entire contents of the abscess, amount-
ing to about a breakfast-cupful of matter. A drainage-tube was now inserted
into the cavity, and through this a weak carbolic solution injected, so as to wash
out completely the interior of the breast. The wound was now dressed by apply-
ing first a piece of lint soaked in carbolic oil, then several layers of dry lint of a
larger size on the top, and over all a thick layer of chloralum wool. The follow-
ing day the dressings were removed. They were thoroughly soaked with serous
oozing, but no more pus had been discharged. The drainage-tube was removed
and the wound dressed as before. On the fifth day the dressings were again
removed and the wound was healed.
The wound in the opposite breast was still open and discharging, and was not
closed for fully a week after this breast had been firmly healed.
The comparative result of treatment in the two abscesses, I think, speaks for
itself. I am well aware of the folly of attaching much importance to a single
case as evidence in any argument ; but, as in other parts of the body, the anti-
septic treatment of abscesses has proved so successful, I think it is not unreason-
able to expect similar good results in mammary abscess. At all events, as I think,
the method deserves a trial.
On the Bearings of Chronic Disease of the Heart upon Pregnancy and
Parturition.
Dr. Angus Macdonald, Lecturer in Midwifery in the Edinburgh Medical
School, terminates an elaborate paper on this subject {Obstetrical Journal of
Great Britain, Nov. 1877) with the following practical deductions : —
1 . Chronic heart disease ought to be looked upon as a grave contraindication
of marriage, more especially if it assumes the form of anything approaching to
severe stenosis of the mitral, or to serious aortic incompetency ; in such cases we
ought, if consulted, to dissuade from marriage.
2. There is much less danger in the case of mitral insufficiency, pure and sim-
ple. But still the risk is even then considerable.
3. In all cases, when consulted, we ought not to give our sanction to marriage
288
Progress of the Medical Sciences.
if in chronic heart disease there are any serious symptoms of cardiac disturbance
present, such as attacks of dyspnoea, breathlessness, palpitation on exertion,
haemoptysis, etc., and this injunction ought to be the more imperative the younger
the patient and the more recent the acute disorder which has given rise to the
chronic lesion.
4. Such patients as are married and have chronic heart disease, ought not to
be allowed to suckle their children, as that appears to tend to keep up the cardiac
hypertrophy, and increase the risks likely to arise from the defective heart.
5. All possible causes of cold and all severe exertion should be avoided during
the pregnancy, if possible, and more particularly during the latter months of it.
6. Premature labour should seldom or never be recommended, because it is so
much more likely to do more harm by disturbing the action of the heart and the
condition of the lungs, than any good it might produce by terminating the evil
effects of the pregnancy. It is to be remembered that relief of symptoms is not
certain after delivery, or anything like certain.
7. The only conditions which seem to warrant the induction of premature la-
bour are the presence of influences which unduly distend the abdomen, and thus
keep the diaphragm in a state of continuous elevation.
8. The same careful principles of management ought to guide us in the case of
a patient with chronic heart disease during pregnancy and the lying-in period, as
in any other state of the system, similarly complicated with heart disease.
9. In almost all the cases I have met with chloroform has been given, and ap-
parently with benefit during delivery. If carefully administered I think it cannot
but be useful in all cases. My reasons for this view are given above.
10. All legitimate means ought to be used to lessen the effects of the down-
bearing efforts, and therefore the judicious and timely application of forceps or of
turning is extremely important. In cases of a large amount of liquor amnii,
timely rupture of the membranes is calculated to be of great service, as it allows
the diaphragm to descend, and thus lessens the embarrassment in the lesser cir-
culation.
On Abnormal Softness of the Nulliparous Uterus, as a Factor in the Etiology of
Uterine Distortions, and as a Cause of Impairment of Power of Locomotion.
At the late meeting of the British Medical Association Dr. Graily Hewitt
read a paper on this subject, in which he stated that eight years ago he directed
attention to the connection between marked distortion of the uterus and impaired
locomotive power, under the designation of "uterine lameness." Further obser-
vations on this subject had led him to the conclusion that a very unusual softness
of the uterine tissues is a nearly constant accompaniment of this tendency to
alteration of shape of the nulliparous uterus ; and the present paper was intended
to illustrate, by clinical data, the connection between the undue softness of the
uterus and its consequent pliability, and impairment of power of locomotion thereon
consequent. A series of twelve cases, taken from the author's private case-book,
from June, 1873, to November, 1874, were related, in which the impairment of
locomotive power, associated with uterine disorder, came under notice in a more
or less typical form. This typical form might be thus described : A young,
generally unmarried, woman ; an invalid for some months or some years ; more
or less feeble ; unable to walk more than a short distance, sometimes only across
the room, without producing aching or severe discomfort ; power of recovering
legs generally present, the impairment not amounting to paralysis, unless in very
extreme cases. Further general characteristics were : A general inability to take
food in proper quantity ; frequent nausea, the latter intensified by the vertical
position ; emaciation, and an approach to actual starvation were observed in long-
1878.]
Midwifery and Gynaecology.
280
standing cases ; menstrual disorders were frequently present, though variable in
nature, The malady was troublesome and tedious in the highest degree; after
months or years of inefficiency, the patient became a confirmed invalid. In the
twelve cases detailed, these symptoms were observed ; and on examination there
were found to be present various degrees of alteration in the shape of the uterus,
together with, in most of the cases, a very abnormal pliability of this organ.
Clinical observation of these cases proved that the difficulty in locomotion arose
from the circumstance that, in the erect posture, the alteration in the shape of the
uterus became intensified. The author called particular attention to the marked
softening of the tissues of the uterus, as a feature most worthy of notice. He
considered it due to an impairment of the nutrition process in the uterus itself.
The general impairment of nutrition was extreme in the cases described ; the
uterus participated ; the general strength having been restored by adequate reme-
dies, the local (uterine) weakness always became lessened in a commensurate
degree. A great cause of this malnutrition of the uterus in young women was
insufficient attention to the dietary during the growing age. The uterus being
unduly j^liable, it was readily flexed and distorted by physical exertions of various
kinds. These distortions gave rise to discomforts and pains of diverse kinds.
Locomotion had the effect of increasing the pains ; and hence, after a time, loco-
motion ceased to be possible. The treatment practised and advocated by the
author consisted, in the first place, of assiduously nourishing the patient ; and, in
the second place, of maintaining the uterus in its proper position and shape so
long as the undue softness persisted. The latter object was secured in some cases
by the maintenance of the horizontal position alone ; in other cases, where the
malady is of long standing, by the assistance of vaginal pessaries, adapted to
restrain the descent of the fundus uteri backwards or forwards as the case might
be. The following propositions embodied the author's views. 1. The discomfort
in walking, or produced by the vertical position, is due to an alteration in the shape
of the uterus. 2. The alteration in the shape of the uterus may be quite tempo-
rary, though, by a process of repetition, it tends to become permanent. 3. A
softened condition of the uterine tissues renders the organ very liable to such
alterations of shape as will give rise to uncomfortable sensations, or even to acute
pain. 4. This softened state of the uterus is usually associated with general
debility of the whole system. 5. The softening is essentially an indication of
malnutrition of the uterus. Dr. Copeman (Norwich) had seen two cases of a
similar character, in which the difficulty of locomotion was mental ; in each case,
there was a slight displacement of the uterus ; he put this right with the finger, and
soon had the patient well again. He considered the symptoms of a nervous char-
acter, and should not think of using pessaries. — British Med. Journ., August
25, 1877.
Ovariotomy during the Course of Acute Peritonitis.
Mr. Lawson Tait, Surgeon to the Birmingham and Midland Hospital for
Women reports (Medical Examiner, Nov. 29, 187 7) four cases of ovariotomy
performed during the course of acute peritonitis, three of which recovered, and
one died. Mr. Tait says, I do not know how to account for the peritonitis in
any one of the four cases narrated, but the complete success of its treatment
by removing the tumour and cleansing the cavity, in three out of the four, induces
me to believe that we may yet venture in the same direction in cases where the
peritonitis is not associated with an ovarian tumour, but with some other cause
which maybe local, or might even be of a more general nature. In such a case,
for instance, as after an operation on the uterus the occurrence of traumatic sup-
purative peritonitis might be treated on the principle of opening and emptying an
No. CXLIX Jan. 1878. 19
290 Progress of the Medical Sciences. [Jan.
abscess. With proper precautions, I do not think that the mere opening of the
abdominal cavity is at all a hazardous operation. I have made a large number
of exploratory incisions, and I have never yet lost a case. In such a condition
as I have supposed, the relieving the peritoneal cavity of the material which is
undoubtedly the source of general systemic poisoning would be an undoubted
benefit. Further I am inclined to believe, that the operative treatment of all
kinds of serious peritonitis is one of the possibilities of the surgery of the future.
MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Acute Poisoning by Acetate of Copper.
Messrs. Feltz and Ritter arrive at the following conclusions (Journal
de Pliarmacie et de Chimie, May). 1. The acetate of copper is more active
than the sulphate 2. The symptoms are much more intense when the animals
are empty. 3. The food and drink take a well-marked taste from the presence
in them of acetate of copper. 4. The appearance of jaundice indicates that in
subacute poisoning by the salts of copper there is produced a supersecretion of
bile, analogous to that occurring in poisoning by arsenic, antimony, and phos-
phorus.
The poisonous dose appears to oscillate between 0.45 and 0.5 gramme per kilo-
gramme of body-weight. Death occurs in 6 to 12 hours after mucous, bilious,
and bloody vomiting, a serous and sanguinolent diarrhoea, and rectal tenesmus,
followed by paralysis of the sphincter ani. Death is immediately preceded by
tetanic convulsions. The loss of weight varies from 750 to 1200 grammes, and
the temperature falls to 95° Fahr.
Analysis gives the quantity of copper found in the liver as from 31 to 34 milli-
grammes in livers weighing 290 to 350 grammes. The urine of dogs poisoned by
the acetate or sulphate of copper always showed notable proportions of the copper
salts ; 1600 cubic centimetres contained about 13 j milligrammes. — London Med.
Record, Nov. 15, 1877.
Toxic Properties of Dynamite.
In a Paris thesis, M. Bruet sums up with the following conclusions as to the
toxic properties of dynamite in nitro-glycerine (Annali Universali di Medicina,
August). 1. Nitro-glycerine is a poison, the energy of which is in direct pro-
portion to the rapidity of its absorption. 2. It is most violent when quickly
absorbed ; a few drops are sufficient to strike down an animal in five minutes, and
death follows in clonic and tonic convulsions. 3. It is less dangerous when
absorbed slowly, and in this case kills by asphyxia, the fatal dose being rather
high. 4. A man exposed chiefly to the absorption of nitro-glycerine has rather
to fear the chronic or slight results than acute poisoning or death. But he should
avoid all conditions which may expose him to rapid absorption of the poison, as
in this case there would be danger of sudden death. 5. For these reasons it is
not superfluous to take precautions agaiitst exposure to an atmosphere in which
particles of dynamite are given off. — London Med. Record, Nov. 15, 1877.
1878.J
291
AMERICAN INTELLIGENCE.
ORIGINAL COMMUNICATIONS.
A Case of Fracture of the Body of the Scapula. By E. T. Easlet,
A.M., M.D., of Little Rock, Arkansas.
Mr. C, a well-developed and athletic white man, 38 years old, applied
to me last September, on account of injuries sustained five days previ-
ously. He had fallen on the track of a street railroad, and the carriage
had passed partially over his prostrate body. The right forearm and thigh
were much bruised and swollen, the skin of the former cut in two places.
The dorsal region of the chest was extensively ecchymosed, and especially
so in the neighbourhood of the shoulder-blade. The scapula itself presented
an irregular, blackened eminence, in which the normal outlines of the bone
were almost entirely lost. By steadying the superior angle of the blade
and pressing downward in a direction corresponding to the natural situa-
tion of the inferior angle, a false point of motion could be distinctly made
out. The diagnosis was a fracture of slight obliquity of the body of the
bone below the spine.
It appeared that the rim or shoulder of the wheel had passed upward
between the internal border of the bone and the spine, separating the
vertebral attachments of the rhomboidei muscles, while the weight of the
opposite side of the wheel falling on the body of the scapula produced the
fracture. The character of the accident and the unopposed action of the
teres major and minor muscles caused the detached fragment to turn up-
ward so much as almost to overlie the spine. It has been laid down that
usually there is not much displacement in fractures of the body of the
scapula.1 Hamilton, however {Fractures and Dislocations, 5th ed. p. 211),
declares that more or less displacement is the rule. Unquestionably in
the present case the deformity was very striking.
It was found almost impracticable to adjust the broken surfaces even
tolerably well, quite impossible to retain them in apposition, and consider-
ing that the fracture was five days old it was not thought best to make
persistent efforts to attain that end. The immobility of the shoulder-joint
was secured by a moulded splint of binder's board and bandage, the forearm
was flexed and supported in a sling across the chest. A broad roller band-
age was then carried firmly around the chest so as to cross the broken
scapula in several directions. The patient was informed that the useful-
ness of .his limb would only be slightly impaired, and that considerable
deformity would remain as a consequence of his misfortune. The prog-
nosis was fully established. The swelling and tenderness rapidly subsided,
Bryant, R. Smith, Liston, Gross,
292
American Intelligence.
[Jan.
the patient complained of but little pain at any time, the strength and
motion of the arm appear to be as perfect as ever, and the deformity of the
shoulder-blade is very perceptible, even when he is dressed in his ordinary
clothing.
Shot fractures of the scapula in army experience are not by any means
uncommon. The Crimean surgeons saw a large number of such wound?,
as did those of the Franco-Prussian war, whilst our own civil war as stated
by Dr. Otis furnished 1423 determined cases of the injury.
The accident for several reasons is very rare in civil life. Unlike the
long bones, the blade is not placed between resisting points, and so is in a
great measure exempt from the effects of indirect violence. Its rounded
and inclined contour and protected situation render it but little liable to be
broken by direct injury. The shoulder-blade, it is safe to assert, is never
fractured except by great direct violence. Only two instances are on
record in which the bone is said to have been broken by muscular action.
One of these, mentioned by Malgaigne, Hamilton evidently regards as
apocryphal, and in the other, that of Mr. May, of England, the bone, as
suggested by Gross, must have been exceedingly brittle from some organic-
defect.
Surgeons have differed widely in relation to the minor details of the
treatment of this injury, and especially as to whether the shoulder should
be elevated, depressed, or allowed to assume its normal position. Again,
it has been advised that the elbow be carried forward ; that it be carried
backward ; that it be taken away from the chest, and that it be firmly
bound to the chest. The essential apparatus is very simple, and need only
consist of a sling for the forearm, and a circular roller bandage for the
thorax. My friend, Dr. Breysacher, of this city, has suggested that the
elastic shoulder-braces might be used to advantage in such injuries, and I
think the idea a good one.
DOMESTIC SUMMARY.
Menstruation and Ovulation.
Dr. T. Gaillaed Thomas, at a meeting of the New York Obstetrical Society
(American Journal of Obstetrics, Oct. 1877), said that he had repeatedly diag-
nosed double ovarian tumour from the absence of menstruation, and the operation
had shown the correctness of his opinion. He felt that the future would show
that menstruation does depend on the function of the ovary.
Dr. Noeggerath said that one case of menstruation persisting after the ova-
ries had been removed would prove the lack of dependence of menstruation on
the ovaries, and many such cases had been collected.
Dr. Thomas mentioned that he had removed both ovaries in ten cases. Two
died ; of the remaining eight, only one had menstruated since the operation.
1878.]
Domestic Summary.
293
Brief Study of the Hundred Cases of Menstruation.
In the number of the American Practitioner for August, 1877, Dr. Theophi-
lus Parvin presents a study of one hundred cases of menstruation observed at
the Indiana Reformatory for Women and Girls. With two exceptions none of
these subjects is more than nineteen years of age, and, four excepted, all are white ;
none married ; and though some have lapsed from virtue, there has been no case
of pregnancy continuing until term, and probably not half a dozen of abortion.
All are natives of the Urfited States, most of them born in the country ; the
majority are daughters of the people, and many of them with little education,
many exposed to cold, illy fed and poorly clothed, and thus subjected to influ-
ences which ordinarily retard the ascension of puberty. On the other hand,
some at least of these girls last referred to have had the force of the retarding in-
fluences lessened, if not destroyed, by licentious associations and acts ; the average
result, then, of this study might be at least an approximation to the truth.
The earliest menstruation was at nine years, the latest at eighteen. The aver-
age age in these one hundred cases, for the first menstruation, is thirteen years
and eight months.
The average duration of the flow in the hundred cases was four days and six
hours ; the longest period being seven to eight days, the shortest twelve to twenty-
four hours.
In more than one-fourth of the cases the duration of the flow was three days, a
larger percentage conforming to this period than to any other.
In sixty-four out of the hundred, menstruation takes place without suffering,
while in the thirty-two others in which pain is observed it is an inconstant phe-
nomenon in fourteen, leaving only eighteen in which it is constant. The painless
performance of menstruation, in so large a proportion of cases, may be attributed
in part to the regular lives these girls live, and the absence of great excitement.
The fact just stated leads me also to believe that it is probable that these hundred
cases, though too small an induction for absolute conclusion, may fairly represent
both the average age of first menstruation and the duration of the flow, as occur-
ring in this country.
Localization of Diseased Action in the (Esophagus.
From a careful anatomical and clinical study of this subject, Dr. Harrison
Allen, Prof, of Comparative Anatomy in the University of Pennsylvania, arrives
(Phila. Medical Times, Oct. 13, 1877) at the following conclusions :
1. Foreign bodies are liable to be retained at the beginning of the oesophagus
behind the cricoid cartilage.
2. Passing this point, they do not, as a rule, reach the cardiac end, or "lower
part," but are apt to be lodged just above the left bronchus as it crosses the
oesophagus.
3. The cricoid region is exceedingly liable to invasion, and if the disease ex-
tends thence downward it is often limited by the left bronchus.
4. It is probable that diseased action may occasionally originate at the point
of greatest narrowing of the thoracic portion, viz., just below the superior tho-
racic aperture.
5. The region of the left bronchus is very frequently attacked, the disease com-
mencing either behind or just below it, and extending thence downward.
6. The cardiac end of the oesophagus is less frequently attacked than either the
cricoid or bronchial portions.
7. Resistance at or near the left bronchus can be detected by a probano- meet-
ing resistance at eleven inches from the teeth.
294
Am E K IC an Intelligen c e .
[Jan.
8. The dangers attending the forcible use of the probang below the region of
the cricoid become more manifest when the anatomical relations of the left bron-
chus are borne in mind.
Relation of the Urinary Organs to Puerperal Diseases.
Dr. W. M. Chamberlain, Physician to Charity Hospital, Xew York, con-
tributes to the American Journal of Obstetrics (April, 1877) an interesting
paper on this subject. His conclusions are as folloAvs : —
1. Acute erysipelatous inflammation of the external genitals may ascend to the
kidney, sometimes by the inner and sometimes by the outer surface of the urinary
tract.
2. The blood of the parturient woman, saturated with fibrine-and poor in
haemoglobin, predisposes her to disease of the excretory organs — the kidnevs and
liver. With a sufficient exciting cause acute fatty metamorphosis takes place.
Fatal cases only are demonstrable, but minor grades of the process are probably
not unfrequent.
3. Lymphangitis limited (cellulitis) and lymphangitis diffuse may mechani-
cally induce acute oedema of the kidney in the puerperal woman by obstruction of
the ureter.
Diphtheritic or other inflammation involving the muscular coat of the bladder
produces the same result.
However excited, oedema of the kidney tends to rapid degeneration both of
the tubular and inter- tubular structure.
4. Diffuse lymphangitis, commonly attending septic processes, by rapid de-
struction of the haemoglobin, tends to the same result, while ulcerative endome-
tritis, suppurative metrophlebitis and cellulitis, tending to pyaemia, not unfre-
quently are productive of metastatic suppurative nephritis.
5. The condition known as uraemia tends to develop peritonitis in parturient
women.
The Post-mortem Imbibition of Poisons.
In a paper read before the College of Physicians of Philadelphia, and published
in their Transactions (third series, vol. iii.), Dr. Reese has discussed the very
important medico-legal question, Whether a poisonous solution introduced into a
dead body, either by the stomach, the rectum, or hypodermically, can percolate
through the tissues, by osmosis, so as to impregnate the contiguous organs, and
thus produce appearances that might give rise to the suspicion that the poison
had been swallowed during life ? It will be remembered that the detection of a
poison after death in the organs of the body is generally regarded by the toxi-
cologist as the most conclusive proof that the death was occasioned by poison —
indeed, far more conclusive than the mere discovery of the poison in the stomach
— since, in the latter case, the noxious substance might possibly have been intro-
duced into that organ after death ; or, even if swallowed during life, it might not
have had time to have been absorbed into the circulation before death took place
from some other cause. The important and interesting question for the legal
physician, then, is, Whether it is possible for a poison to get access into a human
body, after death, and produce appearances in that body similar to, if not identi-
cal with, those resulting from swallowing the same poison during life ? Dr.
Reese very properly remarks that, if the affirmative of this proposition can be
established, a very strong point in legal medicine will be made ; and a very
powerful weapon might thus be placed in the hands of the defence, in a criminal
1878.]
Domestic Summary.
295
trial for poisoning, which may be wielded by a skilful counsel either for good or
evil.
By the intentional method of post-mortem imbibition of poisons, the author
designates those cases in which poisons have been introduced designedly into the
dead body for sinister purposes, and wiUi a view to raise the suspicion of murder
against an innocent person. Although in all the annals of poisoning no mention
is made of any actual instance of this most diabolical crime, yet we find such high
authorities as Orfila and Christisen admitting that it may be quite possible. Dr.
Reese cites a remarkable case that occurred in one of our Western States some
years ago, in which there were certainly very strong suspicions that a dead body
had been thus tampered with for evil purposes. In order to bring the whole
matter to the test of actual experiment, at Dr. Reese's suggestion, a member of
his class at the University, Dr. George McCracken, performed a series of experi-
ments on the dead bodies of dogs, injecting into their stomachs solutions of
arsenic, tartar emetic, and corrosive sublimate, respectively ; then burying the
animals, and disinterring the bodies after the lapse of different periods of time.
The. results given are very striking and conclusive: ''After twenty-one days'
burial, in the case of all three poisonous solutions, on opening the abdomen of the
animal, the characteristic coloured spots of the respective sulphides were observed
on the spleen, the under surface of the liver, and the portion of the peritoneum
posterior to the stomach — ?/e^ow-coloured in the case of arsenic ; red in the case
of antimony ; and black in the case of mercury. Each of the metals was like-
wise discovered by chemical analysis in the liver, spleen, and left kidney. . ..
After forty-four days' burial, the deposit of the different sulphides
was found to be much more decided, in all three cases being noticed on the upper
as well as on the lower surface of the liver, together with the spleen (as in the
first experiment) ; also over the intestines, the omentum, and the kidneys ; and,
in the case of the arsenic, extending as low down as the fundus of the bladder.
By chemical analysis, the poisons were detected in the spleen, liver, and both
kidneys. After fifty- nine days' burial, the results were found to be very similar
to those last mentioned, only more decided, both as regards the quantity deposited
on the various organs in the form of sulphides, and that discovered by chemical
analysis."
Dr. Reese draws attention to the interesting experiments of M. ScolosubofF, of
Moscow, which go to show that, in dogs and rabbits poisoned by arsenic, this
substance is deposited in the brain and spinal marrow in far larger quantities than
in the liver and other organs. As this may presumably be the case also in the
human subject, the author very properly suggests that, in all doubtful cases of
poisoning (especially metallic poisoning), the discovery of the toxic agent in
either of the great nerve centres would settle the question between ante- and
post-mortem poisoning ; ' ' since it is hardly conceivable that a poison introduced
into a body after death could penetrate by imbibition within the cavity of the
cranium or spinal column."
296
American Journal of Medical Sciences.
BELLEVUE HOSPITAL MEDICAL COLLEGE, CITY OF
NEW YORK.
SESSIONS OF 187 7-' 78.
The Collegiate Year in this Institution embraces a Preliminary Autumnal Term,
the regular Winter Session, and a Spring Session.
The Preliminary Autumnal Term for 1877-1 878 will open on Wednesday, Septem-
ber 19, 1877, and continue until the opening of the Regular Session. During this
term, instruction, consisting of didactic lectures on special subjects, and daily clinical
lectures, will be given, as heretofore, by the entire Faculty. Students expecting
to attend the Regular Session are strongly recommended to attend tbe Preliminary
Term, but attendance during the latter is not required. During the Preliminary Term
clinical and didactic lectures will be given in precisely the same number and order as in
the Regular Session.
The Regular Session will begin on Wednesday, October 3, 1877, and end about
the 1st of March, 1878.
FACULTY.
Isaac E. Taylor, M.D., Emeritus Professor of Obstetrics and Diseases of Women, and
President of the Faculty.
James R. Wood, M.D., LL.D., Emeritus Professor of Surgery.
Fordyce Barker, M.D., Professor of Clinical Midwifery and Diseases of Women.
Austin Flint, M.D., Professor of the Principles and Practice of Medicine and Clinical
Medicine.
W. H. Van Buren, M.D., Professor of Principles and Practice of Surgery, Diseases of
Genito-Urinary System, and Clinical Surgery.
Lewis A. Sayre, M.D., Professor of Orthopedic Surgery, Fractures and Dislocations,
and Clinical Surgery.
Alexander B. Mott, M.D. , Professor of Clinical and Operative Surgery.
William T. Lusk, M.D., Professor of Obstetrics and Diseases of Women and Children,
and Clinical Midwifery.
Edmund R. Peaslee, M.D., LL.D., Professor of Gynaecology.
William M. Polk, M.D., Professor of Materia Medica and Therapeutics, and Clinical
Medicine.
Austin Flint, Jr., M.D., Professor of Physiology and Physiological Anatomy, and Seo-
retary of the Faculty.
Joseph D. Bryant, M.D., Lecturer on General, Descriptive, and Surgical Anatomy.
R. Ogden Doremus, M.D., LL.D., Professor of Chemistry and Toxicology.
Edward G. Janeway, M.D., Professor of Pathological Anatomy and Histology, Diseases
of the Nervous System, and Clinical Medicine.
PROFESSORS OF SPECIAL DEPARTMENTS, ETC.
Henry D. Noyes, M.D., Professor of Ophthalmology and Otology.
John P. Gray, M.D., LL.D., Prof, of Psychological Medicine and Medical Jurisprudence.
Edward L. Keyes, M.D., Professor of Dermatology, and Adjunct to the Chair of Prin-
ciples of Surgery.
Edward G. Janeway, M.D., Prof, of Practical Anatomy. (Demonstrator of Anatomy.)
Leroy Milton Yale, M.D., Lecturer Adjunct upon Orthopedic Surgery.
A. A. Smith, M.D., Lecturer Adjunct upon Clinical Medicine.
A distinctive feature of the method of instruction in this College, is the union of
clinical and didactic teaching. All the lectures arc given within the hospital grounds.
During the Regular Winter Session, in addition to four didactic lectures on every
week-day, except Saturday, two or three hours are daily allotted to clinical instruction.
The Spring Session consists chiefly of Recitations from Text-books. This term
continues from the first of March to the first of June. During this Session, daily
recitations in all the departments are held by a corps of examiners appointed by the
regular Faculty. Regular Clinics are also given in the Hospital and in the College
building.
Fees for the Regular Session.
Fees for Tickets to all the Lectures during the Preliminary and Regular Term, including
Clinical Lectures $140 00
Matriculation Fee . 5 00
Demonstrator's Ticket (including material for dissection) 10 00
Graduation Fee 30 00
Fees for the Spring Session.
Matriculation (Ticket good for the following Winter) $5 00
Recitations, Clinics, and Lectures 35 00
Dissection (Ticket good for the following "Winter) 10 00
Students who have attended two full Winter courses of lectures may be examined at the end of
their second courseupon Materia Medica, Physiology, Anatomy, and Chemistry, and, if successful,
they will be examined at the end of their third course upon Practice of Medicine, Surgery, and
Obstetrics only.
For the Annual Circular and Catalogue, giving regulations for graduation and other information,
address- Prof. Austin Flint, Jr., Secretary Bellevue Hospital Medical College.
THE
AMERICAN JOURNAL
OF THE MEDICAL SCIENCES
FOR APRIL, 1878.
CONTRIBUTORS TO THIS VOLUME.
HARRISON ALLEN, M.D., Prof, of Comp. Anatomy in University of Pennsylvania.
JULIUS ALTHAUS, M.D., Senior Physician to Hospital for Epilepsy and Paralysis,
Regent's Park, London.
SAMQEL ASHHURST, M.D., of Philadelphia.
I. E. ATKINSON, M.D., of Baltimore.
WALTER F. ATLEE, M.D., of Philadelphia.
ROBERTS BARTHOLOW, M.D., Prof, of Medicine in Med. Coll. of Ohio, Cincinnati.
FRANK DUDLEY BEANE, M.D., of New York.
HENRY J. BIGELOW, M.D., Professor of Surgery in Harvard University.
JOHN S. BILLINGS, M.D., Surgeon U. S. Army.
CLARENCE J. BLAKE, M.D., Instructor in Otology in Harvard University.
EDWARD H. BRADFORD, M.D., of Boston.
JOHN H. BRINTON, M.D., Surgeon to the Philadelphia Hospital.
CHARLES S. BULL, M.D., Surgeon to the New York Eye Infirmary.
SWAN M. BURNETT, M.D., Led. on Oph., Georgetown Univ., Washington, D. C.
S. C. BUSEY, M.D., Physician to the Children's Hospitccl, Washington, D. C.
S. H. CHAPMAN, M.D., of New Haven, Connecticut.
P. S. CONNER, M.D., Prof, of Anat. and Clin. Surg, in Med. Coll. of Ohio, Cincinnati.
LEARTUS CONNOR, M.D., Prof, of Phys. and Clin. Med. in Detroit Medical College.
WILLIAM C. COX, M.D., Surgeon to Out-DepH of the Pennsylvania Hospital, Phila.
ELBRIDGE G. CUTLER, M.D., of Boston.
C. W. DULLES, M.D., of Philadelphia.
E. T. EASLEY, M.D., of Little Rock, Arkansas.
REGINALD H. FITZ, M.D., Assist. Prof, of Pathological Anat. Harvard University.
WILLIAM S. FORBES, M.D., Surgeon to the Episcopal Hospital, Philadelphia.
HENRY F. FORM AD, M.D., of Philadelphia.
GEO. HENRY FOX, M.D., of New York.
H. J. GARRIGUES, M.D.. of Brooklyn, Nev) York.
R. GLISAN, M.D., Prof, of Obstetrics in Oregon Medical College, Portland, Oregon.
SAMUEL W. GROSS, M.D., Surgeon to the Philadelphia Hospital.
ROBERT P. HARRIS, M.D., of Philadelphia,
HENRY HARTSHORNE, M.D., of Union Sjyrings, N. Y.
W. H. HAYNES, M.D., Attending* Physician to the Eastern Dispensary, New York.
M. H. HENRY, M.D., Surgeon-in- Chief of State Emigrant, Hospital, New York.
CHARLES T. HUNTER, xM.D., Demonstrator of Surg, in University of Pcnna.
JAMES H. HUTCHINSON, M.D., Physician to the Pennsylvania Hospital.
T. N. ISHIGURO, First Surgeon, Imperial Japanese Army, Tokio, Japan.
WILLIAM W. KEEN, M.D., Surgeon to St. Mary's Hospital, Plriladelphia.
A. O. KELLOGG, M.D., of the Hudson River State Hospital, Poughkeepsie, Neic York.
J. H. KING, M.D., Assistant Surgeon U. S. A.
GEORGE M. LEFFERTS, M.D., Clin. Prof, of Laryngoscopy, College of Ph?jsicians
and Surgeons, New York.
F. F. MAURY, M.D., Lecturer on Venereal Diseases, Jefferson Mediccd College, Phila.
THOMAS G. MORTON, M.D., Surgeon to the Pennsylvania Hospital, Pliila.
W. F. MUHLENBERG, M.D., of Reading, Pennsylvania.
PAUL F. MUNDE, M.D., Assistant Sitrgeon to the New York State Woman's Hospital.
JOHN H. PACKARD, M.D., Surgeon to the Ejnscopal Hospital, Philadelphia.
THEOPHILUS PARVTN, M.D., Prof, of Obst. in Coll. of PJiys. and Surg, of Indiana.
CHARLES T. POORE, M.D., Surg, to St. Mary's Free Ho sp. for Children, New York.
F. PEYRE PORCHER, M.D., Prof, of Clin. Med. in Med. Coll. of South Carolina.
B. LINCOLN R AY, M.D., of Philadelphia.
JOHN J. REESE, M.D., Prof, of Med. Jitrisp. and Tox. in University of Penna.
J. G. RICHARDSON, M.D., Professor of Hygiene in University of Pennsylvania.
BEVERLEY ROBINSON, M.D., Physician to Charity Hospital, New York.
CHARLES SMART, M.B., CM., Captain and Assistant Surgeon U. S. Army.
A. A. SMITH, M.D., Lect. Adjunct upon Clin. Med. at Bellevue Hosp. Med. Coll.,N. Y.
ANDREW H. SMITH, M.D., Surg, to Throat Dep't of Manhattan Eye and Ear Hospital,
New York.
GOUVERNEUR M. SMITH, M.D., Phys. to the New York and Presb. Hospitals.
ROBERT M. SMITH, M.D., of Philadelphia.
LOUIS STARR, M.D., of Philctdelphia.
W. H. WEBB, M.D., of 'Philadelphia.
EDMUND C. WENDT, M.D., of New York.
EDWARD WOAKES, M.D., Surg, to Hosp. for Dis. of Throat and Chest, London.
FRANK WOODBURY, M.D., of Plviladelphia.
TO READERS AND CORRESPONDENTS.
All communications intended for insertion in the Original Department of this
Journal are only received for consideration with the distinct understanding that
they are sent for publication to this Journal alone, and that abstracts of them
shall only appear elsewhere subsequently, and with due credit. Gentlemen
favouring us with their communications are considered to be bound in honour to
a strict observance of this understanding.
Contributors who wish their articles to appear in the next number are requested
to forward them before the 1st of May.
Compensation is allowed for original articles and reviews, except when illus-
trations or extra copies are desired. A limited number of extra copies (not
exceeding fifty) will be furnished to authors, provided the request for them be
made at the time the communication is sent to the Editors.
The following works have been received : —
Du Begaiement et de son Traitement Physiologique. Par le Dr. Jules Godard.
Paris : Bailliere & Fils, 1877.
Die Entstehung der Gefahr im Krankheitsverlaufe. Mit besonderen Bench sichti-
gung der Diagnose der Gefahr, •ihren Prophylaxe und Therapie. Von Dr. L. M.
Politzer, A. 0. Prof., Director des ersten oifentlichen Kinderkranken-Institutes in
Wien. Wien : Wilhelm Braumuller, 1878.
Preussische Statistik. XLIII. Beitrage zur Medicinalstatistik des Preussischen
Staates und zur Mortalitatsstatistik der Bewohner desselben, die Jahre von 1870 bis
1876 umfassend. Berlin : Koniglichen Statistischen Bureaus, 1877.
Ein Fall von Thrombotischem Yerschlusse einen der Kranzarterien des Herzens.
Von Dr. A. Hammer. Wien, 1878.
Ueber Injectionem in der Nasen-Rachen-Raum und in die Tuba Eustachii. Von
George N. Acker, aus Washington. Berlin.
Zur Schlaf und Bernhigung erzeugenden Wirkung der Milchs'aure und des Milch-
sauren Natron. Von Dr. A. Auerbach in Berlin.
Medico-Chirurgical Transactions. Published by the Royal Medical and Chirurgical
Society of London. Volume the Sixtieth. London : Longmans, Green, Reader, and
Dyer, 1877.
Transactions of the Obstetrical Society of London. Vol. XIX. For the year 1877.
London : Longmans, Green & Co., 1878.
Saint Bartholomew's Hospital Reports. Editedby W. S. Church, M.D., and Alfred
Willett, F.R.C.S. Vol. XIII. London : Smith, Elder & Co., 1877.
A New System of Medicine, entitled Recognizant Medicine : or, the State of the Sick.
By BnoLAXOTH Rose, M.D. Lond., H. M. Indian Med. Service. London: J. & A.
Churchill, 1877.
Principles of Rational Therapeutics. By Bholanoth Rose, M.D. Lond. London:
J. & A. Churchill, 1877.
On the Treatment of Psoriasis by an Ointment of Chr}'Sophanic Acid. With an
appendix of comments by various authors. By Balmaxno Squire, M.B. Lond.
London : J. & A. Churchill, 1878.
On the Treatment of Chronic Eczema by a Glycerole of the Subacetate of Lead.
Second edition. By Balmanno Squire, M.B. Lond. London : J. & A. Churchill,
1878.
On the Uses of Wines in Health and Disease. By Fraxcis E. Axstie, M.D.,
F.R.C.P. London : MacMillan & Co., 1877.
On Hospital Organization, with Special Reference to the Organization of Hospitals
for Children. By Charles West, M.D., etc. London : MacMillan & Co., 1877.
Spinal Disease and Spinal Curvature ; their Treatment by Suspension and the Use
of the Plaster of Paris Bandage. By Lewis A. Satre, M.D., of New York, Prof, of
Orthopaedic Surgery in Bellevue Hosp. Med. Coll., New York. London: Smith,
Elder & Co., 1878.
301
TO READERS AND CORRESPONDENTS.
Report on Diseases of the Chest, under the direction of Horace Dobell, M.D., etc.
Vol. III. London : Smith, Elder & Co., 1878.
The Pathological Anatomy of Hydrophobia. By W. R. Goaverp, M.D. The Patho-
logical Anatomy of Canine " Chorea." By W. R. Goavees, M.D., Assist. Prof, of Clin.
Med. in Univ. Coll., and H. R. O. Sankey, M.R.C.S. London, 1877.
An Inquiry into the General Pathology of Scurvy. By Ciiarles Henry Ralfe,
M.A., M.D. London : H. K. Lewis. 1877.
Two Lectures. By W. T. Gairdner, M.D. Glasgow : James Maclehose, 1877.
Battey's Operation. By J. Marion Sims, M.D. London, 1*78.
On the Prevalence of Phthisis in Victoria.
Trastornos des Aparato de la Vision en las Fiebres Paludeas. Par el Dr. D. Juan
Santos Fernandez. Habana, 1877.
The Science and Art of Surgery, being a Treatise on Surgical Injuries, Diseases, and
Operations. By John Eric Erichsen, F.R.S., F.R.C.S.^ Surgeon Extraordinary to
Her Majesty the Queen, etc. Revised by the author from the 7th and enlarged English
edition. 2 vols. Philadelphia : Henry C. Lea, 1878.
Landmarks, Medical and Surgical. By Luther Holden, F.R.C.S., Surgeon to
Saint Bartholomew's and the Foundling Hospitals. From the second English edition.
Philadelphia : Henry C. Lea, 1878.
Illustrations of Clinical Surgery. Bv Jonathan Hutchtnson, F.R.C.S. Fasciculi
VIII., IX., and X. Philadelphia: Lindsay & Blakiston, 1878.
Handbook of the Practice of Medicine. By M. Chartiers, M.D., Prof, of Prac. of
Med. Anderson's Coll., Glasgow. Philadelphia : Lindsay <fc Blakiston, 1878.
Lectures on Medical Jurisprudence. By Francis Ogston, M.D., Prof, of Med.
Jurisprudence and Medical Logic in Univ. of Aberdeen. Edited by Francis Ogston,
Jr., M.D. Philadelphia : Lindsay & Blakiston, 1878.
The Elements of Therapeutics. A Clinical Guide to the Action of Medicines. By
Dr. C. Binz, Prof, of Pharmacology in Univ. of Bonn. Translated from the fif th
German elition, and edited, with additions, by Edward I. Sparks, M.A., M B
Oxon. New York : William Wood & Co., 1878.
Cyclopaedia of the Practice of Medicine. Edited by Dr. II. von Ztemssen. Vol.
XIV. Diseases of the Nervous System and Disturbances of Speech. New York : Wil-
liam Wood & Co., 1877.
On the Source of Muscular PoAver. By Austin Feint, Jr., M.D., Prof, of Phys. and
Phvs. Anat. in Bellevue Hosp. Med. CoL, New York. New York : D. Appleton & Co.,
1878.
Pneumono-Dynamics. By G. M. Garland, M.D., Assistant in Physiology, Harvard
University. New York : Hurd & Houghton, 1878.
The Etiologv and Pathology of Chronic Joint Diseases. By Newton M. Shaffer,
M.D. New York : G. P. Putnam's Sons, 1877.
A Handbook of Volumetric Analysis. By Edward Hart, S.B., Fellow of Chemistry
in the Johns Hopkins Universitv. New York : John Wiley & Sons, 1878.
Surgical Uses, other than Haemostatic, of the Strong Elastic Bandages. By Henry
A. Martin, M.D. Boston : James Campbell, 1878.
Prescription Writing. Designed for the Use of Medical Students Avho have never
studied Latin. By Frederic Henry Gerrish, M.D., Prof. Mat. Med. and Therap.
in Med. School of Maine. Portland: Loring, Short, and Harmon, 1878.
Injuries of the Eye and their Medico-legal Aspect. By Ferdinand yon Arlt,
M.D., Professor of Ophthalmology in University of Vienna. Translated, with the
permission of the author, by Chas. S. Turnbull, M.D. Philadelphia : Claxton,
Remsen, & Haffelfinger, 1878.
Approved Plans and Specifications for Post Hospitals, Surgeon-General's Office.
Washington, 1877.
Mortuary Experience of the Mutual Life Insurance Co. of New York, with Tabulated
Reports and an Analysis of the Causes of Death. By G. I. Winston, M.D., W. R.
Gillette, M.D., E. J. Marsh, M.D. Vol. II. New York, 1877.
Two Lectures on Convulsions and Paralysis as Effects of Disease of the Base of the
Brain. Bv Prof. Broavn-Sequard. Stenographicallv reported by Frank Woodburv,
M.D. Philadelphia : Collins, 1878.
Address before the Rocky Mountain Medical Association, containing some Observa-
tions on the Geological Age of the World. By J. M. Toner, M.D. Washington. 1877.
Report on Heating and Ventilation prepared for the Trustees of the Johns Hopkins
Hospital, Baltimore, Md. By John S. Billings, Surgeon U. S. Army, 1878.
Defects of Hearing and other EATils ; the result of Enlarged or Hvpertrophied Tonsils.
By A. W. Calhoun, M.D. Atlanta, 1877.
A Report of Fifteen Cases of Tracheotomy in Diphtheritic Croup. By R. G. Bogue,
M.D. Chicago, 1878.
Remarks on the Brain. By Thomas Dwight, M.D.
The YelloAv Fever at Havana. By Charles Belot. Translated from the French.
Savannah, 1878.
TO READERS AND CORRESPONDENTS.
305
Meteorology in the Science of Medicine. By Dr. J. Schreiber. Translated by W.
H. Geddings, M.D. Louisville, 1878.
On the Recognition and Management of the Gouty State in Diseases of the Skin. On
the so-called Eczema Marginatum of Hebra. Are Eczema and Psoriasis Local Diseases
of the Skin, or are they Manifestations of .Constitutional Disorders? By L. Duncan
Bulkley, M.D.
The Treatment of Fracture of the Femur. By Edward Borck, M.D. Saint Louis,
1878.
Some Thoughts on the Glycogenic Function of the Liver, and its relation to Vital
Force and Vital Heat. By Joseph Le Conte.
Dermatology in America. By James C. White, M.D. New York, 1878.
Surgical Treatment of Intra-Uterine Submucous Fibroids. By E. T. Easlt, M.D.
Louisville, 1878.
Review of Malpractice Suit : Bowley v. Langer.
Observations on the African Yaws, and on Leprosy in Insular and Continental
America. Compulsory Vaccination. Bv Joseph Jones, M.D.
Heart-Clots. By Martin L. James, M.D.
Bathing, Cupping, Electricity, Massage. By David Prince, M.D.
On the Operative Treatment of Vascular Tumours of the Eyelids and Anterior Part
of the Orbit. On the Operations for Traumatic Colobomata of the Eyelids. By H.
Knapp. New York.
The Lymphatic Theorv of Syphilitic Infection. By William A. Hard away, M.D.,
St. Louis. New York, 1877.
Medical Gynaecology. By Fordyce Barker, M.D., of New York.
Higher Medical Education the True Interest of the Public and of the Profession.
Bv William Pepper, A.M., M.D., Prof. Clinical Med. in Univ. of Penna. Philadel-
phia : Collins, 1877.
Is the Human Eye Changing its Form under the Influence of Modern Education ?
By Edward G. Loring, M.D. New York, 1S78.
Malaria and Struma in their Relation to the Etiology of Skin Diseases. By L. P.
Yaxdall, Jr., M.D. Louisville.
A Succinct History of the Plan of Treatment of Pott's Disease by Suspension, and
the Use of Plaster of Paris Bandage. By Lewis A. Sayre, M.D. Louisville, 1878.
The Mechanism and Treatment of Pulmonary Complications of Acute Cardiac Dis-
ease. By Beverly Robinson, M.D. New York, 1877.
On Puerperal Eclampsia. By J. P. Thomas, M.D. Pembroke, Ky.
Spinal Irritation in Children as related to True and .False Arthopathies. By V. P.
Gibney, M.D. New York, 1877.
Etiology of Enteric Fever. By J. L. Cabell, M.D. Philadelphia, 1877.
On the Dressing of Stumps. By Louis Bauer, M.D.
House Air the Cause and Promoter of Disease. By Frank Donaldson, M.D.
Baltimore, 1878.
A Study of Nine Hundred and Sixty-five Cases of Chronic Pulmonary Disease. By
F. H. Davis, M.D. Philadelphia, 1877.
On the Surgical Treatment of Peritj'phlitic Abscess. By J. A. Pooley, M.D.
Columbus, Ohio.
On the Antiseptic Treatment of Wounds and its Results. By Robert F. Weir, M.D.
New York, 1878.
On Certain Points in the Nature and Treatment of Lupus. By Henry G. Piffard,
M.D. Albany, 1877.
Present and Prospective Management of the Insane. By Richard I. Dewey,
M.D. Chicago.
Address in Obstetrics before the American Medical Association, 1877. By James P.
White, M.D., of Buffalo. Philadelphia, 1877.
Transactions of the American Neurological Association for 1877. Edited bvE.C.
Seguin, M.D. Vol. II. New York : G. P. Putnam's Sons, 1877.
Transactions of the Medical Society of the State of New York, 1877. Albany, 1877.
Transactions of the Medical Society of the State of North Carolina, 1877. Salem.
Proceedings of the Medical Society of the County of Kings. Jan., Feb., March, 1878.
Proceeding's of the Association of Medical Officers of American Institutions for
Idiotic and Feeble-Minded Persons. Sessions 1876 and 1877. Philadelphia, 1877.
Proceedings of the American Pharmaceutical Association, Toronto, 1877. Philadel-
phia, 1878.
Minutes of the Life Underwriters' Association of the State of Ohio, June, 1877.
New York Hospital. Report of the Building Committee, together with an Address
delivered on the occasion of the Inauguration of the New Building. By William H.
Van Buren, M.D. New York, 1877.
Annual Report of the Sm*geon-General United States Army, 1877.
Report of the Surgeon-General of the Navy, 1877. Washington, 1878.
Annual Report of the Northern Hospital for the Insane of Wisconsin, 1877. Madi-
son, 1877.
306
TO READERS AND CORRESPONDENTS.
Annual Report of the State Lunatic Hospital at Northampton, 1877. Boston, 1878.
Annual Report of the Asylum at Walnut Hill, Hartford, Conn. Hartford, 1877.
Annual Report of the State Lunatic Asylum of Mississippi. Jackson, 1878.
Report of the Central Lunatic Asylum (for Coloured Insane), Virginia, 1876-77.
Richmond, 187?.
Report of the Pennsylvania Hospital for the Insane, 1877. Philadelphia, 1878.
Report of the Butler Hospital for the Insane. Providence, 1878.
Report of the Pennsylvania Training School for Feeble-Minded Children, 1877.
Report of the Massachusetts School for Idiotic and Feeble-Minded Youth at South
Boston. Boston, 1878.
Report of the Children's Hospital of the District of Columbia. Washington, 1878.
Report of the Women's Hospital in the State of New York, 1877. New York, 1878.
Report of the Pennsylvania Free Dispensary for Skin Diseases. Philadelphia, 1877.
Report of the Massachusetts Charitable Eye and Ear Infirmary, 1877.
Report of the State Penitentiary for the Western District of Pennsylvania, 1877.
Report of the New York Ear Dispensary. New York, 1878.
Report of the Mountain Sanitarium for Pulmonary Diseases. Asheville, N. C, 1877.
Report of the Board of State Charities of Massachusetts, Jan. 1878. Boston, 1878.
Report upon the Births, Marriages, and Deaths in Rhode Island, 1870. Prepared
under the direction of the Secretaiw of State. By Edwin M. Snow, M.D., Providence,
1877.
The usual journal exchanges have been received ; their individual acknowledgment
is omitted for want of space.
Communications intended for publication, and books for review, should be sent
free of expense, directed to Isaac Hats, M.D., Editor of the American Journal of the
Medical Sciences, care of Mr. Henry C. Lea, Philadelphia. Parcels directed as above,
and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 King
William Street, Charing Cross, London, will reach us safely and without delay.
All remittances of money and letters on the business of the Journal should be ad-
dressed exclusively to the publisher, Mr. H. C. Lea, No. 700 Sansom Street.
The advertisement she^t belongs to the business department of the Journal, and all
communications for it must be made to the publisher.
ERRATA.
In the number for January last —
Page 105, 11th line, after "country" insert "whose statistics are uniform as to
nomenclature, and whose deductions are, therefore, interchangeable, and, if faulty,
uniformly so."
Page 256, V)th line, for " about 5 ounces" read "about ?>)/, drachms."
" 11th " " about 7 ounces" read " about 5 drachms."
" 12th " " 173^ ounces" read " 13 drachms."
CONTENTS
THE AMERICAN JOURNAL
OF
THE MEDICAL SCIENCES.
NO. CL. NEW SERIES.
APRIL, 1878.
ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.
ART. PAGE
I. The Operation of Gastro- Hysterotomy (true Cesarean Section), viewed
in the Light of American Experience and Success ; with the History and
Results of Sewing up the Uterine Wound ; and a full Tabular Record of
the Cesarean Operations performed in the United States, many of them
not hitherto reported. By Robert P. Harris, M.D., Member of the Phila-
delphia Obstetrical and other medical societies. ..... 313
II. Some Clinical Observations upon Reflex Cough. By A. A. Smith,
M.D., Lecturer- Adjunct upon Clinical Medicine at the Bellevue Hospital
Medical College, New York 342
III. Derangement of the Glycogenic Function of the Liver as a Cause of
Bright's Disease. By Gouverneur M. Smith, M.D., Physician to the New
York and Presbyterian Hospitals. ........ 348
IV. On the So-calied Pigmentary Svphilide. By George Henry Fox, M.D.,
of New York 356
Y. On the Visual Acuteness in Ametropia of High Degrees. By Swan M.
Burnett, M.D., Lecturer on Oplithalmology, Medical Department of
Georgetown University, Washington, D.C.. . . . . .362
VI. Lupus of the Larynx, A Clinical Study. By Geo. M. LefFerts, M.D.,
Clinical Professor of Laryngoscopy and Diseases of the Throat, College
of Physicians and Surgeons, New York, etc. . . . . . .370
VII. A Case of Paralysis of the Abductor Muscles of the Vocal Cords pro-
bably due to Sclerosis, affecting particularly the Nerve Roots of the Spinal
Accessory in the Medulla Oblongata and Spinal Cord. By Beverley
Robinson, M.D., Visiting Physician to Charity Hospital, New York, etc. 378
VIII. Case of Specific Stricture of the Rectum ; Antero-posterior Linear
Rectotomy ; Recovery. Remarks on the Operation. By Frank Dudley
Beane, A.M., M.D., of New York City 382
IX. Supra-Pubic Lithotomy. By C. W. Dulles, M.D., of Philadelphia.
With a Table of Operations by this Method during the last Ten Years,
and a Report of a Case by Geo. W. Rachel, M.D., of New York. . . 394
X. The Relief obtained by the Use of Nitrite of Amyl in Two Cases of
Hydrophobia. By W. S. Forbes, M.D., Senior Surgeon to the Episco-
pal Hospital, Philadelphia 402
XI. Brief Account of the Sufferings of a Detachment of United States
Cavalry, from Deprivation of Water, during a period of eighty-six hours,
while Scouting on the "Llano Estacado" or " Staked Plains," Texas.
By J. H. King, M.D., Captain and Assistant Surgeon U. S. A. . . 404
308
CONTENTS.
ART. PACK
XII. On Acute Anterior Myelitis in the Adult. By Julius Althaus, M.D.,
M.R.C.P. Lond., Senior Physician to the Hospital for Epilepsy and Pa-
ralysis, Regent's Park, London. ........ 409
XIII. The Connection between Stomachic and Labyrinthine Vertigo. Bv
Edward Woakes, M.D., London, Surgeon to the Hospital for Diseases of
the Throat and Chest, and to the Metropolitan Dispensary for Diseases of
the Ear, London. . . . . . . . . . . .419
XIV. Is Phthisis Pulmonalis Contagious, and Does it Belong to the Zvmotic
Group? By W. H. Webb, M.D., of Philadelphia. . . . . 42G
XV. Chronic Muscular Symptoms after Trichinosis. By Edmund C. Wendt,
M.D., of New York 434
XVI. Wound of the Trachea; Bloody Expectoration and Emphysema fol-
lowing ; Tracheotomy not performed ; Recovery. Communicated, with
Remarks, by Walter F. Atlee, M.D., of Philadelphia 439
XVII. Report of Six Cases of Contagious Vulvitis in Children. By I. E.
Atkinson, M.D., of Baltimore 444
XVIII. A Commonly Accepted Theory in Ophthalmic Physiology Dis-
proved by a Crucial Experiment. By Henry Hartshorne, M. D., of Union
Springs, N. Y 447
XIX. Successful Treatment of Strychnia Poisoning by the Hypodermic In-
jection of Apomorphia. By R. Glisan, M.D., Professor of Obstetrics,
etc., in the Oregon Medical College, Portland, Oregon. .... 448
XX. Backward (Subacromial) Dislocation of the Head of the Humerus ;
Reduction on the Twenty-ninth Day. By P. S. Conner, M.D., Profes-
sor of Anatomy and Clinical Surgery in the Medical College of Ohio, etc. 450
XXI. On the Primary Anassthesia from Sulphuric Ether. By John H.
Packard, M.D., Surgeon to the Episcopal Hospital, Philadelphia. . . 452
REVIEWS.
XXII. Spinal Disease and Spinal Curvature. Their Treatment by Suspen-
sion, and the Use of the Plaster of Paris Bandage. By Lewis A. Sayre,
M.D., of New York, Professor of Orthopaedic Surgery in Bellcvue Hos-
pital Medical College, New York, etc. 12mo. pp. ix., 121. London:
Smith, Elder & Co. Philadelphia : J. B. Lippincott & Co., 1878. . 453
XXIII. Diseases of the Nervous System; Their Prevalence and Pathology.
By Julius Althaus, M.D., M.R.C.P. Lond., Senior Physician to the Hos-
pital for Epilepsy and Paralysis, Regents Park, etc. etc. 8vo. pp. xvi.,
366. New York: G. P. Putnam's Sons, 1878 459
XXIV. A Compend of Diagnosis in Pathological Anatomy, with Directions
for making Post-mortem Examinations. By Dr. Johannes Orth, First
Assistant in Anatomy at the Pathological Institute in Berlin. Translated
by Frederick Cheever Shattuck, M.D., and George Krans Sabine, M.D.
Revised by Reginald Heber Fitz, M.D., Assistant Professor of Patho-
logical Anatomy in Harvard University. With numerous additions from
MS. prepared by the Author. 8vo. pp. xxxvi., 440. New York:
Hurd & Houghton, 1878 465
ANALYTICAL AND BIBLIOGRAPHICAL NOTICES.
XXV. Medico- Chirurgical Transactions. Published by the Royal Medical
and Chirurgical Society of London. Second series. Vol. xlii. 8vo. pp.
lxviii., 335. London: Longmans, Green, Reader, & Dyer, 187 7. . .475
XXVI. Pneumono-Dynamics. By G. M. Garland, M.D., Assistant in
Physiology, Medical Department, Harvard University. 8vo. pp. xi., 155.
New York: Hurd & Houghton, 1878. 478
XXVII. Ueber Percussion der Knocken. Vortrag Gehalten am ersten
Sitzungstage des VI. Congresses der Deutschen Gesellschaft flir Chirurgie
zu Berlin, Am. 4, April, 1877. Von Dr. A. Lucke, Professor der Chi-
rurgie in Strasburg. Archiv fur Klin. Chir. xxi. 187 7.
CONTENTS. 309
ART. PAGE
On the Percussion of Bones. By Dr. A. Liicke, Professor of Surgery at
Strasburg. ............ 482
XXVIII. Lectures on Clinical Medicine ; delivered in the Royal and Wes-
tern Infirmaries of Glasgow. By Lfr. McCall Anderson, Professor of
Clinical Medicine in the University of Glasgow. With illustrations. 8vo.
pp. 268. London: Macraillan & Co., 1877. . . . . . 485
XXIX. Internal Urethrotomy, with its Modern Improvements. By Edward
Lund, F.R.C.S., one of the Surgeons to the Manchester Royal Infirmary,
and Professor of Surgery in the Owens College. 8vo. pp. 33. London:
J. & A. Churchill, 187 7'. 487
XXX. The Science and Art of Surgery: being a Treatise on Surgical In-
juries, Diseases, and Operations. By John Eric Erichsen, F.R.S.,
F.R.C.S., Surgeon Extraordinary to Her Majesty the Queen, etc. Re-
vised by the author, from the seventh and enlarged English edition. 2
vols. 8vo., pp. 947, 989. Philadelphia: Henry C. Lea, 1878. . .48 8
XXXI. Vorlesungen iiber Allgemeineund Experimented Pathologic Von
Dr. S. Strieker, o. o. Professor der Allgemeinen und Experiment ellen
Pathologie in Wien. 1 Abtheilung. Wien: Wilhelm Braumuller, 1877.
Lectures on General and Experimental Pathology. By Dr. S. Strieker, Pro-
fessor [of General and Experimental Pathology in Vienna. Part First.
Vienna, 1877. . 492
XXXII. Illustrations of Clinical Surgery. By Jonathan Hutchinson,
F.R.C.S. Folio, pp. 173-191. Philadelphia: juindsay & Blakiston,
1877. 494
XXXIII. Landmarks, Medical and Surgical. By Luther Holden, F.R.C.S.,
Surgeon to St. Bartholomew's Hospital. From the Second English edi-
tion. 12mo. pp. 128. Philadelphia: Henry C. Lea, 1878. . . 496
XXXIV. Transactions of State Medical Societies.
1. Transactions of Texas State Medical Association, April, 1877, pp. 242.
2. Transactions of the Medical Association of the State of Alabama, April,
1877, pp. 190. •
3. Transactions of the Medical Society of New Jersey, May, 1877, pp. 270.
4. Transactions of Medical Association of Georgia, April, 187 7, pp. 198.
5. Transactions of Minnesota State Medical Society, June, 1877, pp. 180.
6. Transactions of Kentucky State Medical Society, April, 1877, pp. 216.
7. Transactions of New Hampshire Medical Society, June, 1877, pp. 119.
8. Transactions of Medical Society of North Carolina, May, 1877, pp. 88.
9. Transactions of the Medical Society of the State of Pennsylvania, June,
1877, pp. 310.
10. Transactions of the Indiana State Medical Society, May, 1877, pp. 169.
11. Transactions of the Kansas Medical Society, May, 1877, pp. 79. . 497
XXXV. Transactions of the Canada Medical Association. Tenth Annual
Meeting, Montreal, Sept. 12 and 13, 1877. Vol. I. 8vo. pp. 244. Mon-
treal, 187 7. . . 506
XXXVI. Transactions of the American Neurological Association for 1877.
Vol. II. Edited by E. C. Seguin, M.D. 8vo. pp. lxi., 227. New York,
1877 507
XXXVII. Transactions of the New York Pathological Society. Vol. II.
Based on the Proceedings of the year 1875, and largely supplemented from
the records of 1844 to 1877. Edited by John C. Peters, M.D., President
of the Medical Society of the County of New York, etc. 8vo. pp. xvi.,
291. New York: Wm. Wood & Co., 1877 508
XXXVIII. Public Hygiene in America. Being the Centennial Discourse
delivered before the International Medical Congress, Philadelphia, Sept.
1876. By Henry I. Bowditch, M.D. With Extracts from Correspon-
dence from the various States. Together with a Digest of American
Sanitary Law, by Henry G. Pickering, Esq. 16mo. pp. 498. Boston,
Mass.: Little, Brown & Co. London: Trubner & Co., 1877. . . 510
XXXIX. Du Begaiement et de son Traitement Physiologique ; par le Dr.
Jules Godard. 8vo. pp. 64. Paris: J. B. Bailliere & Fils, 187 7.
310
CONTEXTS.
ART. PAGE
Stuttering, and its Treatment on Physiological Principles. By Dr. Jules
Godard. . . . . . . . . . . . .511
XL. Two Lectures on Convulsions and Paralysis as Effects of Disease of the
Base of the Brain. Delivered by Prof. Brown-S6quard before the Phila-
delphia County Medical Society, Feb. 1878. Reported by Frank Wood-
bury, M.D., Reporting Secretary. Pamphlet. Pp. 32. Phila.. 1878. . 512
XLI. The Action of Medicines." By Isaac Ott, A.M., M.D., formerly
Demonstrator of Experimental Physiology, University of Pennsylvania.
8vo. pp. 168. Philadelphia : Lindsay & Blakiston, 1878. . . . 513
XLII. The Elements of Therapeutics. By Dr. C. Binz, Professor of
Pharmacology in the University of Bonn. Translated from the fifth Ger-
man edition, by Edward I. Sparks, M.A., M.B. Oxon. 12mo. pp. 347.
New York: Win. Wood & Co., 1878 515
XLIII. Die Formen des Harnrohrentrippers und die endoskopischen Befunde
derselben; von Dr. Jos. Grunfeld in Wien. Aus d. Med. Jahrbiichern
IV. Heft 1877.
The Varieties of Urethral Catarrh and their Endoscopic Appearance. By
Dr. Jos. Grunfeld, of Vienna. . . . . . . . .516
XLIV. The Treatment of Spina Bifida by a New Method. By James
Morton, M.D., Professor of Materia Medica, Anderson's University.
8vo. pp. viii., 120. Glasgow: James Maclehose, 1877. . . .51 7
XLV. On Hospital Organization, with Special Reference to Hospitals for
Children. By Charles West, M.D., etc. etc. 24mo. pp. 97. London:
Macmillan & Co., 1877 ". . . .517
XL VI. Fourth Biennial Report of the State Board of Health of California.
For 1876 and 1877. 1 2mo. pp. 92. Sacramento, 1877. . . . 519
XL VII. Report upon the Census of Rhode Island, 1875; with the Statis-
tics of the Population, Agriculture, Fisheries and Shore-Farms, and Manu-
factures of the State. By Edwin M. Snow, M.D., Superintendent of the
Census. 8vo. pp. clix. and 159. Providence, R. I., 1877. . . . 520
QUARTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.
Anatomy axd Physiology.
The Functions of the Retina.
On the Colouring Matter of
PAGE ] PAGE
. 521 Retina in its Relation to Vision,
the I By Kuhne. . . . .523
Materia Medica and Therapeutics.
Thymol; the new Antiseptic. Dr.
Hans Ranke. .... 524
On the Mydriatic Properties of
Duboisia Myoporoides, with an
Account of its General Physio-
logical Action. By Mr. John
Tweedy and Dr. Sydney Ringer. 526
The Action of Diuretics. By
Grutzner. . . . .527
Diuretic Properties of the Hydro-
broniate and Citrate of Caffeine.
By Professor Gubler. . . 528
Quinetum and its Therapeutical
Value. By Dr. H. J. Vinkhuvsen. 528
On the Therapeutic LTses of Sul-
phate of Copper. By Drs. G.
Levi and D. Barduzzi. . . 529
Excretion of Alcohol by the Kid-
neys and Lungs. By Professor
Binz ..... 530
CONTENTS.
311
Medicine.
page
Melaena Neonatorum. By Dr.
Lederer. ..... 530
Ascites from Syphilitic Hydremia.
By Dr. Carlo Dal Monti. . .531
On the Use of Ozonic Ether and
Lard in Scarlatina. By Dr. J ohn
Day. . . . . 531
On the Treatment of Erysipelas by
Silicate of Soda. By Dr. Alva-
renga. . . . . .532
New Symptom of Paralysis Agi-
tans. By M. Debove. ' . . 532
Lesions of the Anterior Nerve-
Roots in Diphtheritic Paralysis.
By Dr. J. Dejerine . . . 533
Pathology of Tetanus and Hydro-
phobia. By Dr. Joseph Coats. 533
Carbolate of Soda in Whooping-
cough. By M. Pernot. . . 534
Treatment of Syphilitic Laryngitis.
By M. H. Duret. . . .534
The Treatment of Asthma. By
Professor Germain See. . .535
Use of Pure Creasote in Pulmonary
PAG E
Phthisis. By MM. Bouchard
and Gimbert. . . . .537
The Diagnosis of Extra-Pericardial
Adhesions. By Dr. O. yon Wid-
mann. ..... 538
On the Treatment of Serous Effu-
sions by Limitation of Fluid in
the Food. By Dr. W. B. Chea-
dle .„538
On Visceral Syphilis. By M. Lan-
cereaux. ..... 540
On Syphilitic Disease of the Kidneys
and Heart. By Dr. Axel Key. 541
Milk-diet in the Treatment of Ne-
phritis. By Dr. H. Mackiewicz. 542
Cerebral Commotion as a Cause of
Transient Glycosuria. By M.
Albert Robin 543
Lesion of the Pancreas in Certain
Forms of Diabetes. By M. Lan-
cereaux. ..... 543
Use of Nitric Acid in Diabetes In-
sipidus. By Mr. Henry Kennedy. 543
Symptoms and Treatment of Pso-
riasis Universalis. By Kaposi. . 543
Surgery.
Parenchymatous Injections of Ace-
tic Acid in Carcinoma. By Dr.
Th. Gies. . . .
.Arnica as a Remedy for Boils. By
Dr. Planat.
Foreign Bodies in the (Esophagus.
By Prof. B. von Langenbeck. .
Foreign Body in the (Esophagus,
with Perforation of the Aorta.
By Dr. Aschenborn.
On Surgical Treatment of Bron-
chocele. By Prof. Billroth.
Tracheotomy in Diphtheria. By
Dr. R. A. Kronlein.
Laryngo-Tracheotomy for Large
Multiple Papillomatous Growth
in the Larynx ; Removal of the
Vocal Cords ; Preservation of
Voice ; Coexistence of Thoracic
Aneurism. By Dr. Burney Yeo.
A Case of Total Extirpation of the
Larynx ; Death on the Fourth
Day. By Dr. Gerdes. .
A simple Plan of Emptying the
Pleural Cavity. By Dr. Girgen-
sohn. .
A Successful Case of Extirpation
of the Spleen. By Dr. A. Mar-
tin. ......
Extirpation of Kidney. By Prof.
Kocher. .
544
545
545
549
550
551
552
555
555
556
557
Case of Congenital Ventral Hernia
successfully treated. By Prof.
F. Rizzoli 558
Excision of Hard Chancre as a
Preventive of Syphilitic Infec-
tion. By Auspitz. . . . 559
Syphilis of the Testis in Young
'Children. By Dr. Henoch. . 559
Congenital Malposition of the Tes-
ticle successfully treated by
Operation. By Thomas Annan-
dale 560
Prostatic Tumours removed du-
ring Lithotomy. By Mr. Thomas
Bryant. . . . .560
Treatment of Cystitis. By Mr.
Robert Persse White. . .561
Pseudo-Membranous Cystitis and
its Treatment. By M. Guyot. . 561
The Pathological History of Cysto-
Phosphatic Deposits. By Sir
Henry Thompson. . . .561
Glycerine in the Treatment of In-
ternal Hemorrhoids. By Dr.
David Young. . . . .562
Ulcers from the Use of Enemata.
By Professor Koester. . .563
Production of Local Artificial Anae-
mia as a Means of treating Dis-
eases in the Extremities. By
Dr. Bernard Cohn. . . .563
312
CONTEXTS.
PAGE
Pathogenesis of Genu Valgum. By
M. Verneuil. .... 565
Curious Case of Ulceration of In-
ternal Carotid. By Dr. Erichsen. 5G5
Anomalous Case of Fusion of the
Radial Artery with the Median
Basilic Vein, simulating an Ar-
terio- Venous Aneurism. By Dr.
Challot. ..... 565
Spontaneous Perforation of the Pop-
PAGE
liteal Artery in a Case of White-
swelling. By Dr. Bard. . .566
Employment of Catgut to arrest
Hemorrhage from a Bone. By
Dr. Riedinger. . . . .566
Subcutaneous Fracture of Exosto-
ses. By Mr. Maunder. . . 566
Subcoracoid Dislocation of the Hu-
merus by Muscular Contraction.
By Dr. G. Lapponi. . . .567
Ophthalmology and Otology.
Migraine of the Eye. Dy Dr.
Galezowski. .... 568
Salicylate of Soda in Rheumatic
Iritis. By Dr. Galezowski. . 569
Acute Glaucoma following a Single
Instillation of Atropia. By Dr.
Hugo Magnus. .... 569
Appearance of the Fundus in Gene-
ral Anaemia. By Dr. Hirschberg. 570
Retinitis Pigmentosa without any
Pigment visible with the Oph-
thalmoscope. By Prof. Huidiez. 570
Retinal Aneurism. By Dr. Briere. 571
Treatment of Paralysis of the Mus-
cles of the Eve! By Prof. J.
Michel 572
Binocular Accommodation. By Dr.
Theodore Rumpf. . . .572
Therapeutic Use of Electricity in
Ophthalmology. By A. Bergh. 572
Midwifery and Gyn ecology.
Dislocation of the Xiphoid Carti-
lage during Pregnancy. By M.
Polaillon. . . . . 573
Normal Labour during Extra-Ute-
rine Pregnancy. ByM. Labutut. 574
Ano-Pelvic Version. By M. Gue-
niot. . . . . .574
On the Treatment of Post-partum
Hemorrhage by the Injection of
Hot Water into the Uterus. By
Dr. Lombe Atthill. . . .574
Prophylaxis of Puerperal Fever.
By Dr. Zweifel. . . .576
Digitalis in Metrorrhagia. By M.
Desnos. ..... 576
Report of a Fifth Series of Fifty
Cases of Ovariotomy. By Dr.
Thomas Keith. . . .576
Medical Jurisprudence and Toxicology.
Successful Treatment of Opium J Poisoning by Atropia. By Dr.
| Milner Fothergill. . . .578
AMERICAN INTELLIGENCE.
Original Communications.
A Tasteless Antiperiodic. By i
Samuel Ashhurst, M.D., of Phil-
adelphia. . . . . .579
Ligatures made from the Sinew of
the Whale. By T. N. Ishiguro,
First Surgeon, Imperial Japa-
nese Army. Communicated bv
Samuel D. Gross, M.D., Prof,
of Surgery, Jefferson Medical
College, Philadelphia. . .580
Domestic Summary.
Perityphlitis and its Treatment.
By Dr. Sands 581
On the Use of a Mixture of Bro-
mides and Chloral in Epilepsy.
By Dr. E. C. Seguin. . " . 583
Extirpation of the Spleen. By
Dr. G. B. Simmons . . . 583
Diagnosis of Sciatic Dislocation of
the Hip. By Dr. W. W. Daw-
son. ...... 584
Poisoning by Custards and Ice
Creams. By Dr. J. S. Well-
ford 584
THE
AMERICAN JOURNAL
OF THE MEDICAL SCIENCES
FOR APRIL, 1878.
Article I.
The Operation of Gastro-Hysterotomy (true Cesarean Section),
viewed in the Light of American Experience and Success ; with
the History and Results of Sewing up the Uterine Wound ; and
a full Tabular Record of the Cesarean Operations performed
in the United States, many of them not hitherto reported. By
Robert P. Harris, M.D., Member of the Philadelphia Obstetrical and other
medical societies.
Eight years ago, we commenced to collect the records of the Cesarean
operation in the United States, and in February, 1872, published the
result of our labour in a resume of 57 cases, and a tabular statement of 59,
which may be found in the 4th vol. Am. Journal of Obstetrics, We are
now to fulfil a promise of a more extended research that we made at that
time, a work of no little labour, when the extent of our country and its
sparsely settled condition in many sections are considered. We were
fortunate in having access, through the libraries of the College of Physi-
cians and Pennsylvania Hospital, to a large proportion of the published
cases ; and what these did not supply have been furnished by private
collections. When these sources failed, we entered upon an extensive corre-
spondence with leading physicians in every State in the Union, and espe-
cially with active members of State medical societies, and by their aid
canvassed the country in all directions from Maine to Texas, and Virginia
to California. In this way more than 28 per cent, of the cases in the
tabular record have been rescued from oblivion. Care was taken to reject
all reports of operations, in which the uterus had not been incised, as
many such were sent to us under the call for Ccesarean cases. We
could, no doubt, have doubled our list, and materially diminished the
relative mortality by accepting them ; but they do not belong to the
No. CL April 1878. 21
314 Harris, The Operation of Gastro-hysterotomy. [April
Caesarean operation, and would have very much lessened the value of
our statistics.
It might be thought that gastrotomy, or more correctly etronotomy,
performed after rupture of the uterus, for the removal of the foetus, and its
secundines, should prove to be a more severe and fatal operation than
gastro-hysterotomy, but such does not appear to be the case, and for two
reasons, viz. : —
1. Where the operation is performed, the necessity for promptness is
generally realized by the accoucheur and surgeon.
2. The subjects of rupture are as a general rule much more robust, and
in much better health than those who submit themselves to the Caesarean
section, many of whom are rickety dwarfs, or the subjects of cancer,
pelvic exostosis, tumours, etc.
The abdominal cavity is quite tolerant of the presence of blood and
liquor amnii for a limited period, and where they are carefully removed
under the knife, there appears to be less cause for apprehending perito-
nitis, than there is where gastro-hysterotomy has been performed upon a
patient exhausted by long labour. Promptness of action in either case
vastly diminishes the mortality, and in our own country causes the rate
of success to very nearly approach that claimed for ovariotomy.
When we entered upon the research which has resulted in the prepara-
tion of tlys paper, we were actuated by a desire to disabuse the minds of
American physicians of the impressions made upon them by the teachings
of most of the obstetrical works found in their libraries in the English
tongue ; which, with few exceptions, either emanate from Great Britain,
or are biassed in favour of trans-Atlantic opinions, touching the dangers of
the Ca?sarean operation. And whilst, of course, desirous of being able to
make as favourable a report as possible, we have laboured with all diligence
to obtain records of cases without any regard to their success or failure, as
we shall be able to demonstrate before we conclude. If statistics are to
be valuable, they must be unbiassed, thorough, and complete, and no pains
or trouble are to be esteemed too great in accomplishing this end. "We are
quite sure that many of our correspondents will give us the credit at least
of perseverance, in some of our searches after unrecorded operations. We
might have made a more favourable report, if we could have been satisfied
with the records already published, but we were determined to reveal as
much of the whole truth as it was possible to obtain, and in so doing,
have increased the mortality by 16 per cent. We have indeed heard of
unrecorded favourable cases sufficient to cover this, but are unwilling to
accept of any reports, that do not give the year, and certain definite points,
coming from reliable authority.
The statistics of Great Britain and Ireland, as prepared by Dr. Radford,
of Manchester, show a frightful mortality after the Cesarean section, and
the opposition to the operation on the part of English obstetricians and
1878.] Harris, The Operation of Gastro-hysterotomy. 315
surgeons is not to be wondered at. We have extended the record of Dr.
Radford, but it will be most convenient for our purpose to take the first
hundred cases, as the few that are over are scarcely any more encourag-
ing. The one hundred operations saved the lives of but 16 women,
although 57 children were removed alive. Of 46 cases in which the pelvis
was contracted from malacosteon, but 5 were saved, and of 21, the result
of rickets, but 1 was saved, 24 women were operated upon within the
first twenty-four hours after the commencement of labour, and 7 were saved.
Of the 16 cases that resulted favourably, 5 were deformed from malacos-
teon, 1 from fracture of the pelvis, 1 from rickets, 4 had cancer, 2 exos-
tosis, and 1 anchylosis of hip-joint.
There is an unaccountable fatality that attends this operation in Great
Britain, which is far in excess of that reported by continental authorities,
and found to result in our own country. Of the first 34 on the English
record, but 2 were saved, against 19 of the first 34, on our own table.
This difference has been thought by some to be due to malacosteon, a
disease of exceedingly rare character in the United States, so much so,
that many physicians in large practice have never met with a case : yet
this disease prevails on the continent, and has been one of the causes of
difficulty in the operations performed by Frederick Winckel, who has
operated more frequently, and with better proportionate success, than any
man living. It is true that he regards a case of osteomalacia as much less
promising than one deformed from rickets ; still he has saved several, by
his plan of early operating. By this he secures prompt uterine contraction,
and has never used a uterine suture, or had a death from hemorrhage. But
the cases of rickets appear if anything less favourable in Great Britain
than those of malacosteon. There must, therefore, be something at issue,
either in the climate, or the habits of the women operated upon, to account
for 17 deaths in 24 cases in which there was no unreasonable delay. In
our own record we have 37 operations upon subjects with deformed pelves,
of whom 15 were dwarfs, and nearly all had been affected with rickets in
early life. There was no instance of mollities ossium among them. The
dwarfs varied in height, from 3 feet 2 inches, to 4 feet 6 inches, two of
them weighing but 65 and 70 pounds respectively, and were certainly not
promising subjects for so severe an operation : yet of the 37 women, 17
were saved, and several are still living and in good health. Only 11 of
the 37 had the advantage of being operated upon before the close of the
first day of labour, and seven of them were saved.
Dwarfs — There were, in all, sixteen dwarfish subjects operated upon
in the United States in the past forty-two years, all with pelves deformed
by rickets, except two, one being infantile, and the other having an exos-
tosis from the sacrum, and it will be of interest to mark the result in their
cases. Seven had the advantages of an early operation, and four of them
were preserved ; whilst of the nine who were operated upon, after more or
316
Harris, The Operation of Gastro-hysterotomy.
[April
less delay beyond twenty-four hours of labour, eight died, and but one
recovered. Of the sixteen children, ten were saved. The five dwarfs
saved, were 3 feet 9 inches — 3 feet 11^ inches — 4 feet 6 inches — 4 feet —
and 4 feet 6 inches, respectively in height, and were all operated upon at
an early period but one, who had been in labour thirty-eight hours. All
of their children were saved but one, which was delivered alive, but being
a deformed fetus soon died. Can there possibly be any better evidence
than this, of the value and importance of promptness, where the Cesarean
operation is to be resorted to, to save the life of the mother? We do not
require to consult the statistics of the Old World to know what are the
prospects of recovery in the New. These are valuable in some respects,
but should not have undue weight in forming the opinions of American
accoucheurs and surgeons. The subjects of the operation in all countries
have been very largely derived from the lower classes, and it is a question
to be considered what amount of influence upon the prospective results
may be due to their diet, mode of living, and drinking habits. We know
by hospital experience, that excessive indulgence in stimulants, and
particularly in malt liquors, very markedly unfits the subject for safely
enduring an injury, or a surgical operation. No nation (although the
inhabitants are by no means generally robust or well fed), appears to be
better prepared to endure with safety the most severe operations of surgery,
than the Chinese, in their own country. And although much is no doubt
due to an innate constitutional immunity, a great deal is also to be attributed
to their freedom from intemperance in the use of alcoholic stimuli. We
are inclined to believe, that much of the want of success in the Coesarean
operation in Great Britain, depends upon the beer-drinking habits of the
peasantry,1 else why should skill and promptness be so entirely thrown
away in the great majority of cases in which they have been exercised?
In speaking of early operative assistance we have been obliged of neces-
sity to establish a limit of time, and have made it twenty-four hours from
the commencement of labour ; but this by no means marks the measure
of promptness on the part of the surgeon, who may lose his patient by the
exhaustion consequent upon delay within this period.2 The rule of Winckel,
to operate before the membranes are ruptured, is an important one, where
the obstacle to delivery-is known early enough, which is too rarely the case.
In both of Dr. Gibson's operations upon Mrs. M. Reybold of this city,
this plan was pursued, and in neither was the patient exhausted by previ-
ous suffering: the reports do not state the time, but we have learned that
ten hours of labour had passed when the second operation was performed.
In both instances was the operation one of election, the woman having
1 See favourable cases of Dr. James Edmunds, Med. Times and Gaz., Jan. 5, 1861 ;
Med. Press and Circular, Nov. 1876, p. 445.
2 See Case 13 in table.
1878.] Harris, The Operation of Gastro-hysterotomy.
317
twice before at great risk and after hours of suffering, been delivered under
craniotomy. These two successful operations of Prof. Gibson have been
very valuable in their instructive influence upon American surgeons, and
we can trace this effect in 6 operations with 4 recoveries, that occurred
at a much more recent period, in the hands of graduates of the University
of Pennsylvania, whose students were each session for several years, shown
by Prof. Hodge the two Cesarean children of Mrs. E. in illustration of
his lecture upon " Gastro-hysterotomy." At the time of Prof. Gibson's
first operation in 1835, there was very little known as to the prospective
results of the Cesarean section in this country, and the experience of
British authorities was anything but encouraging. It required, therefore,
a considerable degree of boldness, in an operator undertaking the case,
especially as it is said that Dr. Physick was unwilling to risk his reputa-
tion upon it. The triumph and credit were, therefore, all the more merited
by Prof. Gibson. In reviewing the history of the operation prior to that
period, we find 35 British cases with 33 deaths, and 6 American ones with
2 deaths. It is possible that the favourable results in two of the latter
may have been known to Prof. Gibson ; but Dr. Nancrede, who was
accoucheur in the case, and subsequently its reporter, and who seems to
have endeavoured to search out the American records, does not appear to
have heard of the operations of Dr. Estep, of Ohio, in 1833 and 1834 ;*
JSros. 5 and 6 in our tabular record. The chief encouragement he had,
was in the record of Baudelocque, and a belief that the danger would be
materially lessened by operating before the membranes were ruptured.
Burns' English record of 23 cases and 22 deaths gave him but little to
hope for. We are inclined to exalt the successful surgeon, but certainly
great credit is also due to Dr. Joseph G. Nancrede for his management of
the case, both before and after the operation. His was the first case in
our country to demonstrate the advantages of operating, before the patient
began to feel exhausted from the duration of her labour, and the first in
which both mother and child were saved.
Cases operated upon more than once — Besides Mrs. Reybold, there
were four women operated upon a second time, and one a third time, viz.,
Nos. 5 and 6, before referred to — woman saved. Nos. 17 and 22, woman
saved in first, and the child also in the second. Nos. 29, 31, 35, woman
saved in first, child likewise in second, and wroman lost in the third, but
child saved. Nos. 36 and 55, woman and child saved by first, and both
lost in the second operation. Nos. 45, 49, woman and child saved in
first, and both lost in second; making in all, thirteen operations on six
women, with the loss of three women and five children. No. 35 died of
peritonitis after the third operation, which was performed early. No. 49
died of the same disease, probably induced by the removal of her ovaries,
1 They were not reported in print until 1836.
318 Harris, The Operation of Gastro-hysterotomy.
as she had recovered from a former operation. Xo. 55 was affected with
dysentery at time of operation, when five months pregnant, and died of
entero-peritonitis. Eight of the operations were performed early, and all
resulted favourably but one (35).
Causes of Death in the Women The "fons et origo" of fatality may be
found, in a large proportion of cases, in the exhausted state of the patient
at the time when the operation is commenced. Death is generally attri-
buted to peritonitis, prostration of system, septicemia, etc.; but it is
wTell known that these are largely determined by the previous condition of
the woman. Peritonitis, like erysipelas, is often an adynamic type of
inflammation, and as we sometimes see repeated attacks of the latter in
feeble subjects, or in paralyzed extremities, so we find the former attack-
ing those who have been first worn out by a long tedious labour, and
attempts to deliver by the hand or craniotomy, and then operated upon by
the abdomino-uterine section. With a pulse of 130 or more per minute,
as we often see recorded, it is not to be wondered at that the patient dies.
Although but 17 out of 71 operations were performed early, there was
manifested but little disposition on the part of our surgeons to add to the
delay already existing, after they became satisfied of the necessity of ope-
rating. There is a g eat reluctance on the part of many to perform the
operation, and it has often been declined when success might have attended
it; but we find no such instance of censurable postponement as the follow-
ing, reported by an American eye-witness, in the first number of the
Phila. Med. Examiner: On November 29, 1837, a woman of about four
feet in height, and twenty-five years of age, presented herself in labour to
M. Cazeau, as he was on his morning round at the Hopital Clinique in
Paris. kShe was immediately examined in a private room ; pelvis found
much deformed, and child alive. A consultation was called, and gastro-
hysterotomy decided upon ; but instead of performing it at once, it was
postponed until the next morning at half-past eight o'clock. By this time
the woman was exhausted by a labour of thirty-six hours, and although
the operation was well performed by M. Moreau, the child was lost, and
the mother died during the following night. This result is certainly not
to be wondered at. We should be glad to be able to represent this as an
isolated case, but European reports, especially British, give instances
where the delay was quite as unaccountable.
Peritonitis Of 37 deaths, 16 were attributed to this cause; 3 being
operated on early, and 13 after a labour of from thirty hours to several
days. In four cases craniotomy was first performed ; in four, much time
was lost by their being in the hands of ignorant midwives. Xo. 3 was
doing well about ten days; dined on animal food, with cider; violent peri-
tonitis set in, and death resulted in forty-eight hours. No. 9 got up very
imprudently on fifth day, and died on the 8th. Xo. 49 had her ovaries
removed at the time of the operation, under direction of the planter to
1878.] Harris, The Operation of Gastro-hysterotomy. 319
whom she belonged, to secure her barrenness ; hence, no doubt, the fatal
result. No. 63 was considered almost hopeless at the time of operation,
from long delay under a widwife, and craniotomy. And No. 64, after
forty-four hours' labour, had a profuse hemorrhage under the knife, and
died in forty-two hours.
Exhaustion and Nerve-shock It is difficult to draw the distinction, in
many cases, between these conditions and peritonitis, as they not unfre-
quently coexist. The evidences of violent peritoneal inflammation appear
to have been seldom found in those cases which were examined after
death, the physical conditions existing prior to the operation no doubt
moderating the severity of the inflammatory action. Where patients have
died in a few hours, peritonitis has not been developed ; but in No. 62,
who lived but twenty hours, there was general peritoneal congestion with-
out effusion, and several ounces of lochia were found in the abdominal
cavity.
Eight cases of death were attributed to exhaustion, all after long labours
but the one just referred to. No. 14 was in labour several days, and her
case was considered almost hopeless at the time of the operation ; she died
in an hour. In Nos. 38 and 48, much valuable time was lost under mid-
wife mismanagement. In the latter, which was an arm presentation, the
midwife lied ruptured the membranes, and given ergot; she survived the
operation twelve hours. In No. 30, after a labour of fifty hours, and a
failure in an attempt at craniotomy, death resulted in four hours after the
operation. No 53 was operated upon after long delay, did well for three
days, was frightened and excited by a quarrel in her room, which she
attempted to quell, and died in twelve hours.
Septicaemia. — Uterine phlebitis and septic poisoning would no doubt
have taken a more prominent place among the causes of death, if autopsies
had been generally, instead of rarely performed. There would appear
from the history of Cesarean cases to be a marked opposition, on the part
of relatives and friends of those who die after the operation, to having
their bodies any further subjected to the knife ; and hence post-mortem
appearances are seldom recorded, and, when given, are rarely minute in
character. Nos. 51 and 59 only were attributed to septicemia ; the latter
being a case in which first an extra-uterine and then an intra-uterine
foetus were delivered alive, and were living some time afterward ; no au-
topsy. Child of No. 51 still living (Nov. 1877).
Convulsions Three cases died in convulsions. No. 25 was in labour
seventy -two hours when the accoucheur arrived ; was seized with eclamp-
sia during an examination ; pelvis much deformed ; no abatement of con-
vulsions after operation ; died in twelve or; fifteen hours. No. 37 did well
four days ; went into convulsions from indiscretion in diet (eating dump-
lings), and died in two hours. No. 65 had Bright's disease, and died in
sixty hours of ursemic poisoning.
320
Harris, The Operation of Gastro-hysterotomy. [April
Strangulation of Intestines — This is very rarely a cause of death, but
is mentioned as such by several authors, the obstruction resulting from a
loop of intestine passing into the uterine wound. Both this and omentum
have at different times been found thus constricted. No. GO was no doubt
one of intestinal strangulation effected in this way, although the operator
was somewhat at a loss to account for it, as no autopsy could be secured.
Strangulation may also be produced by the abdominal wound. Baude-
locque mentions finding a portion of intestines strangulated in the uterine
incision, and advises, in case the symptoms indicate this condition, that
the abdomen should be opened, and the bowel withdrawn. A uterine su-
ture would possibly have saved the life of Case 60, as she does not
appear to have had the symptoms of peritonitis, but simply those of in-
testinal obstruction.
Hemorrhage from Incomplete Closure of the Uterine Wound Death,
simply from loss of blood, appears to be very rare, and we have found no
instance in this country of dying in the operation. The loss of blood
during the operation is generally moderate, and easily controlled. A large
uterine sinus will sometimes bleed profusely, and so will the placenta
when cut into, or its place of attachment, when laid bare beneath the line
of incision. The uterus, after death, is sometimes found lilled with a
coagulum, extending through the gaping incision, and into the abdominal
cavity, associated with lochial discharge and puruloid fluid; but in such
cases there are generally symptoms of local or general peritonitis, and oc-
sionally uterine softening or gangrene. The uterus, after a long and
exhausting labour, sometimes becomes of a liver or chocolate colour, and
appears, when incised, to have undergone a material structural change. It
is not to be wondered at, that a gangrenous gaping wound should be found
after death, or that septicemia should terminate the life of the patient.
To avoid uterine inertia or complete atony \ and an unfavourable closure
of the incision in the uterus, an early, and, if possible, an elective opera-
tion should be performed.
Causes of Death in the Children There were 73 children delivered
from the 71 Cesarean cases (two bearing twins), and of these 36 were
dead, and 37 alive, of whom 5 died within ten days — saving, therefore,
32. This is a much greater mortality than has occurred in European,
and especially Continental, cases. The causes of death were mainly more
or less connected with long delay ;l for in the seventeen early operations, all
of the children but one were removed alive, and fourteen of them lived,
some of them to have children of their own in after life. Of the 36 chil-
dren removed dead from the uterus, 6 had been destroyed by instruments ;
2 were premature; 3 had died from disease in utero; 8 perished from
long delay under the management of ignorant midwives ; 1 from the same,
1 See special tabular statement in this Journal for July, 1872, page 290.
1878.] Harris, The Operation of Gastro-hysterotomy.
321
under a charlatan; 6 from impaction in the pelvis and long labour;
4 from expectant treatment too long relied upon before operating; 2 from
neglect, the mother being operator, and delivering herself on a snow-
bank ; and 1 not stated. Although not directly reported, there are rea-
sons for believing that in one-third of the cases the long delay is to be
attributed to the ignorance of midwives, many of the women being slaves.
Obstacles to Delivery through the Pelvis In 37 women the pelvis was
more or less deformed, chiefly from rickets, and, as we have remarked
before, in no case from malacosteon, almost an unknown disease in our
country; and in two cases the arm presented as an "additional complica-
tion. In 9 cases the soft parts were so occluded or contracted that manual
and instrumental entrance was impossible. In 6 there was exostosis
within the pelvis; in 2, tumours formed an obstruction below; and, in 2,
within the uterus. In 5 cases the foetus was impacted transversely in the
pelvis, nothing being said of the latter being deformed.
In No. 28, the pelvis is reported as fully three inches in the conjugate
and transverse diameters. The propriety of the operation is very ques-
tionable. No. 43 was badly managed by a midwife, the uterus empty of
fluid, and foetus immovable. Every effort was made to deliver per vias
naturales, but failed. No. 46 resembled it. No. 47 was like 43. and
also under a midiuife ; liquor amnii evacuated sixteen hours before she
called assistance. No. 48 resembled the last, and, to make matters
worse, the midwife had ruptured the membranes and administered ergot.
No. 52, with shoulder presentation, gives a good example of the diffi-
culties of foetal impaction. Labour had lasted sixty hours, and liquor
amnii had been long evacuated. The arm was amputated ; version by
vertex and feet both tried in vain, and evisceration of thorax and abdo-
men with like result, owing to the distorted and impacted state of the
foetus ; and yet this woman had been delivered naturally of seven chil-
dren.
No. 41 is reported as a case of impacted head, the position being sim-
ply an occipito-posterior one, and the pelvis not deformed. As the head
was said to have been visible at the vulva for twenty hours, we cannot
understand why neither the forceps nor craniotomy was resorted to. Dr.
Cooper had diagnosed twins, although there was but one foetus. We see
nothing to justify the operation in this instance.
In these seven cases of impaction, although the children were all lost,
all the women were saved but one, who died of exhaustion in twelve
hours (No. 48).
No. 27 is also a case of impacted head ; but as the operation was per-
formed quite early, and the mother and child were saved, we cannot see
why instruments were not used, if attainable, and the operation thus
avoided. We have but a very imperfect record of the case. As the
operation has been performed by a razor, a butcher-knife, or the imple-
322
Harris, The Operation of Gastro-hysterotomy. [April
ments of a pocket-case, which in a sparsely settled region are more easily
obtained than forceps or craniotomy instruments, it may be that the ne-
cessities of the case left no choice of action but the one adopted. It is
one thing to manage such cases in a city, where appliances and competent
assistants are readily attainable, and quite another in a wild and thinly
settled country, perhaps many miles away from your own home. All the
operations in our record performed for impaction of the foetus, amount to
nine in number, and resulted in saving seven of the women. It is an
easy matter to sit quietly at home in a large city, and say what should
have been done under the rules of science in these cases ; can it be prom-
ised that the results would have been more favourable ? We well remem-
ber a parallel case that occurred a number of years ago. A prominent
obstetrician of this city was called to see a young German woman in vio-
lent labour, and suffering severely from delay in her delivery. Failing of
success, he called in consultation two of the most skilful men of their day,
and a plan of action was agreed upon. The woman had been in labour
four days, and the child was still alive. By much perseverance and after
long manipulation the foetus was removed dead, per vias naturales, under
the most approved method of treatment ; but the woman died of exhaus-
tion the next day. We do not say that gastro-hysterotomy should be
resorted to in such cases, as there is a possibility of delivery without it ;
but when we come to the question of relative safety to the mother, it is a
matter for grave consideration which of the two plans is shown by statis-
tics to be the less dangerous, and to promise the more favourable results.
In our own country we believe that the Cesarean operation would be
preferable to and less dangerous than that of embryulcia, in cases where
the patient has been long in labour, and to whom the immediate relief of
the knife is all important ; and that the shock is less dangerous from the
incision of the uterus than the exhaustion and injury of the tissues re-
sulting from a long, tedious extraction. In the former there is a danger
of death only, whilst in the latter, if this is escaped, there are left in many
cases the frightful results of inflammation and destruction of tissue, to
which death might be thought preferable.
Improvements in destructive instruments have, in recent days, increased
the facilities for removing the foetus in cases of extreme deformity of the
pelvis, but it is very questionable whether it would not be better in all
instances, where the conjugate diameter of the superior strait is less than
two and a quarter inches, and in many of. even two and a half inches, to
resort to the Csesarean operation as early in the labour as possible. The
late Dr. Parry, of this city, admitted to be a man of skill, was nearly seven
hours in delivering a foetus through a conjugate diameter of two inches ;
the woman had an attack of peritonitis, and narrowly escaped death ; and
the doctor resolved, in case she should again become pregnant, to deliver
her by gastro-hysterotomy, believing it to be less dangerous and every
1878.] Harris, The Operation of Gastro-hysterotomy. 323
way preferable. Having his mind directed by this case to the question of
relative mortality in Caesarean and craniotomy subjects, he prepared a
valuable article, entitled1 " The Comparative Merits of Craniotomy and
the Cesarean Section in Pelves with a conjugate diameter of two and a
half inches or less," in which he clearly shows that, in skilful hands, the
former has no advantage over the latter in the record of recovery, whilst
the sequela? of the first are far more to be dreaded.
Dr. Parry appends to his paper a tabular record of seventy eases, just
one less than our own, with a fatal result in twenty-six women, or in 37^
per cent. It will be remarked by any one examining it, that the eases,
with scarcely an exception, were under the care of obstetricians of well-
known reputation, residing either in cities or large towns, among- them
being such names as Ramsbotham, Hicks, Greenhalgh, Barnes, Dubois,
Radford, C. D. Meigs, and Fordyce Barker. This is, therefore, as fair a
showing for themselves as the opponents to gastro -hysterotomy have any
right to demand, and a far more favourable one than a general statement
like our own would be, if made without any regard to special skill or ad-
vantage.
To make a fair comparison between our record, and that of Dr. Parry
on craniotomy (under skilful management), we have selected the cases
belonging to cities and important towns, where, as a general ride, they
would be supposed to have had the best advantages of treatment ; and find
them to number 32, with a saving of 20 women and 16 children, or a loss
of 37^- per cent, against the 37^ in his table, which is almost an exact
balance, without counting the advantage of having saved 50 per cent, of
the children. Or take the converse, and we show a saving of 62-^ per
cent, of women, against 62y per cent, under " craniotomy in pelves having
a conjugate diameter of '2\ inches or less." This is a very remarkable
result, when we consider that by this method of exclusion, we count but
9 out of 17 early operations, and include 3 out of the 5 deaths which
occurred in the 1 7. It was certainly not in the large cities that the most
favourable cases were undertaken, for 8 out of 17 early sections were
made in country places, many of them very remote from the centres of
civilization. In such localities men of remarkable skill and attainments
are sometimes found in our country, as we have been made conscious of,
since we commenced the preparation of this paper ; but we secure a higher
average degree of skill, by confining our calculation to the more favoured
localities.
By another mode of calculation, we select the cases that were under-
taken with the great advantage of an early resort to the knife, excluding
all that had been in labour more than twenty-four hours, and we find but
seventeen reported of this variety. With this advantage, and without
1 Am. Journ. of Obstetrics, vol, v. 1872, p. 644.
324 Harris, The Operation of Gastro-hysterotomy. [April
any very marked superiority of surgical skill, except in a few instances,
we find a saving of life in 70 per cent, of the women, and 80 per cent, of
the children. Now apply the best skill of the country to a succession of
early operations, and what is to prevent a result nearly or quite on a par
with ovariotomy ?
Our calculations of success are based upon our own statistics, and have
no reference to those of any other country. In Great Britain, as before-
mentioned, the views of the profession are generally adverse to the Cesa-
rean operation, because of its fearful mortality : Dr. Greenhalgh of London
is one of its few advocates, and became such, through an unfortunate expe-
rience in craniotomy in small pelves, having lost five out of six women,
and saved the remaining one after she had had an attack of peritonitis.
Dr. Greenhalgh visited Dr. Frederick Winckel of Germany, saw some of
his cases, and heard of his remarkable success ; but his own eight opera-
tions have resulted in death to all the women but one, although he had the
satisfaction of having saved five of the children. This mortality is not
much to be wondered at, except in regard to two of the cases. Five of
the women were in a diseased condition, three from cancer, and two from
progressive softening of their bones (malacosteon). Three were better
subjects, having been deformed by rachitis in childhood, but in only one
of these was the operation performed early. In one instance, we notice
that the pulse beat 140 before the operation, and 180 after it : and it is
not surprising that death resulted in eighty hours, when we learn that the
woman had been four and a half days in labour. Two cases operated
upon after six and twelve hours of labour respectively, one of rickets and
the other malacosteon, were both fatal. With this return for care and
skill in operating, it is very natural that the operation should be looked
upon as " the forlorn hope," and that premature delivery by craniotomy
should be recommended as a substitute. We are only just assuming an
independence of judgment in regard to the propriety of gastro-hysterotomy,
and beginning to understand that here at least there is a very fair pros-
pect of success, if the operation is performed before the patient becomes
exhausted by long labour. Our English medical brethren are too apt to
think that their want of success will be attributed to a relative deficiency
of skill, and on this account are disposed to doubt the accuracy of the sta-
tistical statements of other countries ; when, if there is any fault in their
surgery, it lies at the door of too long delay, in which respect this country
is by no means in advance in the measure of time, although there may have
been a less disposition to procrastinate, after the operation was deemed
inevitable.
The proportion of early operations in Great Britain and Ireland, as well
as in the United States, has been about 24 per cent., there being but a
small fractional difference in favour of the latter. In the former, with no
question of skill in management, there was a loss of 71^ per cent, and in
1878.]
Harris, The Operation of Gastro-hysterotomy.
325
the latter but 30 per cent. We must, therefore, in all charity, attribute
our advantages to the climate, and the character of the subjects our opera-
tors have had in charge. Although British statistics do not show it,
there ought to be a decided difference in favour of rachitic subjects, who
suffer from the effects of a former, over those with malacosteon, in whom
there is a present disease ; and were all cases operated upon early in
labour, we should expect to see this difference made manifest. There
should also be a difference under the same advantages, in cases of the
latter disease, according to the stage of progress at the time of the labour.
Fortunately we have not this disease to contend with ; but as the country
becomes more densely populated, and the low poor, more degraded, and
poorer fed, Ave shall have more cases of rachitic deformity in our large
cities. We see the evidences of it in our almshouses, and among the chil-
dren playing in the small streets and lanes of our cities, particularly those
of African descent. We have not as yet noticed the peculiar walk, pro-
duced by a rachitic pelvis, so often met with in the streets of Paris, in
short, but healthy looking white women, but possibly we may have this
condition developed as our cities become older, in which event, the ques-
tion of craniotomy or gastro-hysterotomy will more frequently present
itself to the mind of the accoucheur.
The Operation Both the history and the method have been so often
examined into and described, that we shall confine our discussion to a few
points of interest. It is a curious fact, if it be such, that the first Cesarean
operation on the continent of Europe was performed by a cattle-gelder ;
that the first in the United Kingdom of Great Britain and Ireland was by
a midwife ; and that the first in Jamaica, as well as in the United States,
was done by a woman on herself ; at all events these are the first on
record as far as known at the present day. It has been said that an ope-
ration was performed in 1491, nine years before that of Jacques Nufer,
the gelder on his own wife ; but the statement is not at all reliable, as
many also think with regard to the Nufer operation itself.
After various changes in the direction and locality of the abdominal
incision, the world of surgeons finally settled down to that in the linea
alba, or, as some prefer it, through the edge of the rectus abdominis ; and
nearly all of the operations in this county have been done in this way ;
No. 25 was performed in the linea semilunaris, and No. 13, in a dwarf of
three feet six inches, was, to obtain space, done by the oblique incision.
Where the recti muscles have become separated by abdominal distension,
as they are sometimes by several inches, it becomes of more than usual
moment where the incision should be made to obtain a secure union, and
avoid hernia, or the giving way of the parts in a future pregnancy, as has
happened. It is in such cases that it becomes most important to incise
through the edge of the rectus.
It is a question whether the use of anaesthetics is not in some instances
Harris, The Operation of Gnstro-hysterotomy. [April
•iin obstacle to success in this operation, by producing attacks of vomiting,
and causing inertia of the uterine muscular tissue. By the ether spray
the first may be avoided, but the method is not an advisable one to be
applied to the uterus itself.
As the prevention of intestinal protrusion is an important one, and
requires that the assistants should have full command of the abdomen, so
as to make a properly directed and even pressure, it has been proposed by
Prof. Edward W. Jenks, of Detroit, and carried out in an operation suc-
cessfully performed by him last June, that the surgeon should take his
stand between the lower extremities of the patient, so as not to interfere
with the said assistants in their portion of the operation. Although this
operation has been performed with success without medical assistance,
and by means of a very imperfect armamentarium, those who have done
it have very much felt at the time the want of both. In a few instances,
under competent assistance, the intestines have been kept entirely out of
view during the operation.
Uterine Sutures. — For a long period there was a decided difference of
opinion as to whether the abdomen should be sewed up, or the lips of the
wound held in apposition by adhesive strips: and the question is still in a
measure unsettled, whether the wire stitches should avoid or be passed1
through the peritoneum ; but the vital question of the day is, Shall the
uterine wound be left to nature, or sewed up, and, if the latter, how and in
what way shall it be done? This is not a new question, but a very old
one revived, which for seme reason was for a long period lost sight of.
No doubt it was at one time occasionally employed, but little has been
written of it in the imperfect records that have been handed down to us.
When Mr. Spencer Wells proposed the use of sutures in the uterus, before
the London Obstetrical Society at its meeting on March 4, 1863, he did
not appear to be aware that the plan M as by no means a new one, nor does
the record of the proceedings show that any other member present knew
that this was the case. In 1865, both Spencer Wells and Sir James Y.
-Simpson made use of sutures as proposed ; the former tried a long unin-
terrupted silk one, and left an end out of the vagina, by pulling on which
the whole was removed after several days ; and the latter employed three
sutures of iron wire. Of eight Caesarean operations that year in Great
Britain, this of Mr. Wells was the only one not fatal. The woman was
not in labour, and but five months pregnant, but her uterus had been punc-
tured by a trochar in the operation of ovariotomy, and the evacuation of
the organ was thought imperative.
In 1867, Drs, T„ Beers Townsend, of New Haven, Connecticut, and
D. Warren Brickell, of New Orleans, Louisiana, each employed uterine
sutures in their respective cities, and both of the women are alive and
1 Ovariotomists usually favour passing the wire .sutures directly through the perito-
neal coat.
1878.]
Harris, The Operation of Gastro-hysterotomy.
327
well to-clav ; the first used three of fine hemp, and the second, six silver
ones. Dr. Brickell, in a private communication, says that he had advo-
cated the use of the uterine suture both in the Ceesarean operation, and in
cases of rupture of the uterus, in his course of obstetrical lectures, as early
as 1856, and had been somewhat ridiculed for what were considered rather
wild opinions. From the record of his operation it would appear next to
impossible that the woman could have been saved without closing the
uterine wound, as there was no contraction, she having been in labour ten
days.
Looking back in history we find no mention of the uterine suture for a
number of years. Blundell, in his later edition1 (1840), simply remarks
that ^suture of the uterus has not generally been hitherto employed."
Searching over a long series of French and English authorities, we find
with this exception no mention of the uterine suture ever having been used,
the language of Cazeau that "the uterine wound demands no other precau-
tion than that of being cleaned," being the character of direction usually
given. In the comprehensive Dictionnaire de Medecine, pa ■ MM. Ade-
lon, Beclard, Berard, Biett, etc. etc., Paris, 1834, we, however, find this
reference: "The uterine wound does not demand any other care, although
an unskilful surgeon did introduce sutures, which it was found necessary
to remove."
In 1833 and 1834, Dr. Eobert Estep, of Stark County, Ohio, performed
two successful Cesarean operations upon the same woman (Cases 5 and 6),
and in his report of the same, we find this remarkable language: "I have
made no mention of sutures applied to the wound in the uterus as recom-
mended by some authors, and I take occasion to express unqualified dis-
approbation of their employment. The indissoluble suture I consider
dangerous; the animal ligature to say the best useless" Dr. Estep quotes
no authorities, but for a backwoods surgeon, many of whom were by no
means backward in knowledge, he appears to have been much better posted
up than some of our contemporaries who have tried and been forced to
abandon the catgut suture within the past ten years, for the simple reason
that the knot will slip and open in any part of the body, where it is kept
from becoming dry and hard.
Going back to the early days of our own record (Case 3), we find an
exemplification of the old adage, "fools enter in where angels fear to tread,"
in an operation performed by a Virginia charlatan in 1828, in which he
sewed up the uterine incision with two or three stitches. This man en-
joyed quite a reputation among the country people in his vicinity, and
although the operation in question was bunglingly done, there is every
reason to believe that the woman would have recovered, but for an indis-
cretion in eating, before referred to.
1 Principles and Practice of Obstetric Medicine, London,
328 Harris, The Operation of Gastro-hysterotomy. ["April
Hull (1799), in his "defence of the Cesarean operation," gave it as his
opinion that the wound of the uterus had " very rarely been stitched.'
He recommended the glover suture, with higher end left out of the abdo-
minal wound for its removal by traction.
M. Lebas (1769), of Mouilleron, France, during the period when the
transverse incision was usually practised, operated upon the wife of a
farmer after this method, incising the uterus in the same direction, and
closing the wound in this viscus by three stitches. The woman recovered,
although she had been three days in labour before the operation. (Hull,
op. cit.) In the same year Martha Rhodes died of secondary hemorrhage,
which might have been prevented by sutures. She survived the operation
but five hours.
In the last eleven years there have been sixteen cases of Cesarean sec-
tion in the United States, and of these, ten were dressed with the uterine
suture, and eight were thus treated out of the last ten operations. In No.
62 Prof. Sager used four silver sutures in the uterus of a dwarf, in which
there was a small uterine fibroid in the incision, and much hemorrhage.
The woman died in twenty hours, and the uterine wound was found gap-
ing, allowing the escape of lochia into the peritoneal cavity. No. 61 was
a case in which one suture was introduced by Dr. C. F. Rodenstein, and
removed by Dr. De Marmon in thirty-six hours. The case was one of
long delay, twenty-three hours being lost in waiting for assistance, and
terminated in death, in forty-two hours, by metro-peritonitis. No. 65 was
fatal by reason of Blight's disease in the last stage — ten uterine sutures of
silk were used, as the wound gaped open, and their ends brought out at the
lower end of the abdominal incision. No. 66 was also fatal, having been
under the care of a midwife, and has already been referred to under the
head of " Dwarfs." Two silver sutures were used on account of hemor-
rhage. No. 67 died shortly after the operation, from hemorrhage and
exhaustion, one silk uterine suture was used to arrest the hemorrhage. No.
68 is also referred to in the section on dwarfs, as one of the successful
cases; one silk suture was inserted. No. 69, in the same section, had
three silver stitches used. Died in five days, and uterine wound found
gaping. No. 71 was in labour seven days — -four silver sutures inserted in
uterus. Woman reported in excellent health quite recently — operation
last June.
In the old world the suture has been repeatedly tested, and with vary-
ing results, during the last twelve years: silk, catgut, the same carbolized,
silver wire, and caoutchouc covered with silk, as well as iron wire have
been more or less experimented with. Theoretically, carbolized catgut
was the great material, but after numerous trials, some successful, and more
the reverse, even Veit of Bonn, and E. Martin of Berlin, have been forced
to adopt the opinion so long since given of the animal ligature, by Dr,
Estep, of Ohio, and quoted on page 327. In England, the operations of
1878.]
Harris, The Operation of Gastro-hysterotomy.
329
Drs. Meadows, Eoutli, and J. W. J. Oswald were all failures, as the
sutures became untied. Dr. Martin succeeded in a case in 1874, in which
he arrested the hemorrhage by using fourteen catgut sutures, and treble
knotting them; but failed in another, in the way it has often happened.
Dr. Veit was successful on two occasions, using eight stitches in one and
seven in the other, and was at one time a strong advocate of the method,
which some of his countrymen claim to have been original with him ; but it
is immaterial, so far as holding a knot is concerned, whether the catgut be
plain or carbolized. The theory of Dr. Yeit was, that the animal suture
became untied, and fell into the uterus to be discharged, which is no doubt
a fact, but the change unfortunately takes place before union has com-
menced in too many cases. The experiences of London, Berlin, Prague,
and Breslau have been so entirely adverse to the catgut, that we presume
it has about run its day. Dr. Martin has openly condemned the animal
ligature, and now advocates the use of silk. Dr. Giirtler1 saved the life of
a woman from severe hemorrhage by the use of three sutures of this mate-
rial.
Dr. G. Silvestri,2 of Trissino, in Vicenza, Oct. 2, 1873, in a successful
operation, applied four uterine sutures of elastic thread covered with silk,
passing the needle through the entire thickness of the organ ; in applying
each suture, the finger of an assistant was placed between it and the uterus,
so as to prevent too great constriction of the tissues. The ends were cut
off. His design was to keep the edges of the uterine wound constantly in
apposition to secure union, and prevent the exit of fluid into the abdominal
cavity. At the end of six months, the woman and child were reported in
good health, and the uterus was found entirely mobile. Dr. Silvestri3 has,
since his own operation, had an opportunity of witnessing an autopsy of a
woman who died (cause not stated) in thirty hours after her uterus had
been sewed up with silver wire, in which he found a complete union by
the first intention. This has somewhat improved his opinion in regard to
the latter material.
Of all the materials used, that of pure silver wire has the best record of
success, and next to it silk or thread. There has been, and is still, a
strong desire to secure some plan by which the foreign substance shall be
removed after it is no longer required, either by absorption, or the hand
of the operator ; but all experiments, except with the long-tailed inter-
rupted, or the glover suture, have failed. Dr. J. Beers Townsend (Case
56), in a recent letter, states that he placed his stitches so that they should
work into the uterine cavity and be discharged. He does not write how,,
but it is to be presumed that he avoided entirely the peritoneal coat of the
uterus, and tied simply the lining membrane and substance proper of the
1 Archives fur Gynoecol., vol. v. part 3, 1873.
2 Archives de Tocologie, 1874, p. 189. 3 Arch, de Tocol., 1874, p.. 703..
No. CL — April 1878. 22
330 Harris, The Operation of Gastro-hysterotomy. [April
organ. The question has been asked : " What becomes of the silver wire?"
We have seen but one record upon this point, but cannot recall the refer-
ence. The woman died at a period long after the operation, and the wires
were found to have been covered in by an exudation of plastic lymph along
the line of incision, which had become organized, forming a layer of new
tissue over the seat of the wound. The wires had been twisted, cut off
short, and bent down, which is the plan most highly recommended.
The experience of our country is as yet entirely too limited to determine
whether the employment of the uterine suture is, or is not, an improve-
ment in the method of operating. A few cases cannot decide the question,
although some of them would seem to have been saved, when it would
appear almost impossible that any other plan could have answered. The
experience of England is not at all decisive, as there have been so few
women saved ; but the favourable result in the operation of Dr. John
Parks, of Bury, Lancashire, in 187o, where four silver uterine suture-
were used, would seem to show that the plan is not without value. Dr.
Parks attributes his success to the following points: 1. The woman was
of good sound constitution. 2. The operation was performed before the
powers of nature were greatly exhausted. 3. Great care was used to keep
the abdominal parietes in contact with the uterus. 4. The complete
closing of the uterus to prevent any escape of fluid into the peritoneal
cavity. 5. And keeping the patient constantly under the influence of
opium.
Operations upon women long in labour, and some appearances presented
after death, in Cesarean cases have revealed three sources of danger, which
have been the occasion of introducing the uterine suture into very frequent
use. 1st. After a long labour, the uterus fails to contract fully, when the
foetus is removed, and the wound gapes widely, requiring to be held together
to prevent the entrance of the intestines, and the escape of the lochial dis-
charge. 2d. Secondary atony, or relaxation in a once contracted uterus,
may be revealed after death, as the main cause of a fatal termination. A
six-inch incision has been seen to contract at the time of the operation to
an inch and a half, and been found relaxed to four inches or more, and
widely open after death. 3d. Hemorrhage from the cut surfaces in the
uterus, requiring pressure. Even where the uterine incision has been re-
duced to an inch and a half long, the wound has been found open, and
much fluid in the abdominal cavity.
The fear has been that sutures in the uterus would greatly increase the
danger of peritonitis ; but the dangers to be encountered by using them
are often not to be considered, in view of the greater risks in endeavouring
to avoid their employment. In atony, or hemorrhage at the time of the
operation, there can be no question as to the better safety of the suture.
Uterine Drainage In the early days of the Cesarean operation, it
was the common practice to pass a long drainage tent through the uterus
1878.] Harris, The Operation of Gastro-hysterotomy.
331
and vagina, and sometimes from the uterus through the lower end of the
abdominal incision, for the purpose of favouring the discharge from the
womb. This was afterward abandoned as a fruitful cause of danger,
although Winckel still advocates it in a modified form, to keep open the
os uteri. Recently the practice of drainage has been revived in a much
more reasonable style, by means of the tube a drainage of Chassaignac, as
will be seen in the following case.
Dr. T. Mayer1 operated on a woman 30 years old, and 3 feet high (French
measure), on account of an antero-lateral curvature in the lower third of the
spine. The membranes were ruptured before the section, and the fluid
drained off. No blood or fluid escaped into the cavity of the abdomen. The
hemorrhage was checked by sponging with cold water, after which a
drainage-tube was passed through the lower parts of both wounds, and the
ends tied together over the pubes. This tube remained until the sixteenth
day, with no symptoms of metritis, metro-peritonitis, or hemorrhage. The
plan has been tried with success by several operators on the Continent, and
without uterine sutures. Ice was used to check hemorrhage by contraction,
and the whole operation completed as soon as possible. As the contracted
state of the os uteri and vagina are frequently obstacles to the discharge of
the lochia, the use of the drainage-tube would seem to be a valuable im-
provement, particularly as the caoutchouc appears to possess but little irri-
tative property.
The condition of the uterus, where complete involution has taken place
after gastro-hysterotomy, having been rarely examined post-mortem, an
autopsy of Prof. Mayer, of Berlin, in a case eight years after the operation,
will be of much interest. The section was made in 1813, by Dr. Hofrath
Yelten, on a woman of thirty-six, with deformed pelvis, and both she and
child saved. The incision was through the linea alba, and vertically
through the uterus, the wound in the latter being five (French) inches in
length, and between the fundus and neck. Prof. Mayer found that the
uterus had regained its natural form and size, being 2 in. 7 lines long, and
1 in. 10 lines across between the insertions of the Fallopian tubes. The
place of incision was indicated externally by a furrow about one-fourth of
an inch long. " The peritoneum adhered firmly to the substance of the
womb at this point, and covered the furrow above mentioned. The edges
of the wound through the uterus were extremely contracted and drawn in-
wards ; the cicatrix on the inner surface was two lines and a half long."3
The anterior wall. of the uterus near the cicatrix was three lines thick, and
the posterior, opposite to it, four. The patient stated after her recovery,
that the ventral incising felt like drawing a red-hot needle over the skin f
1 Archives de Tocologie, Sept. 1874.
2 Lond. Med. and Phys. Journ., 1829, page 83.
The same was said in 1769 by Martha Rhodes, of London, after her operation.
(Med. Ohserv. and Inquiries, vol. iv., 1772, p. 265.)
f
332
Harris, The Operation of Gastro-hysterotomy. [April
that cutting the uterus was not at all painful ; but that stitching the ab-
dominal wound was the most severe step in the operation. It has been
repeatedly stated that the operation was not any more severe than a vio-
lent natural labour, and this complaint of the sutures is a general one.
The whole process is much less severe than the suffering during a pro-
tracted delivery by craniotomy and evisceration. We stated in the early
portion of this article that we had found no instance in this country, of
death under the operation, and thought then, that this success might
possibly apply to the Old World, but have since learned that a woman
died on the table at Guy's Hospital in 1875, just as Dr. A. L. Galabin
was inserting the last catgut suture in her uterus. Long labour, shock,
and hemorrhage caused her death. The case was one of vaginal occlusion,
in which, from the impossibility of craniotomy, the Cesarean operation
was imperative, and should have been performed early, in which event,
there would have been a reasonable hope of success.
In view of the record we have presented, there is clearly in our country
a much greater fear of performing the operation in question than there
ought to be. We have in this city over 800,000 inhabitants, and have
had one operation in forty years. Will any one pretend to say that this
was the only woman who required it ? We are satisfied that in more than
one instance, women have died undelivered, who should have had the
chance for life which the Cesarean section would have given them. Our
surgeons, with the exception of a few who have devoted special attention
to female surgery, know but little of what has been done in this particular
operation in our country, and when called upon to decide in a case, are
generally glad of some plausible excuse to escape the responsibility which
they feel will be incurred, in case of the death of the woman. If mid-
wives had a better knowledge, and accoucheurs were more prompt in action,
the surgeon would be called earlier in the labour, and might then feel better
encouraged to hope for success. When it is realized that an early opera-
tion offers two to one in favour of recovery, there will be less hesitancy in
performing it. If the woman cannot be delivered per vias naturales, be-
cause of the risk, or impossibility of using destructive instruments, it mat-
ters not whether the cause of difficulty be perfectly understood or not, the
fact of total inability to deliver should decide the point as to the question
of resorting to the Cesarean operation.
Fibroid and cancerous tumours of the inferior third of the uterus are
sometimes serious obstacles to delivery, and may render it impossible to
introduce either the hand or crotchet, or even make a satisfactory diagnosis
of the difficulty. We hold that in such a case, it would be better to make
an exploratory incision in the abdomen, than follow an expectant plan,
with no hope of anything being accomplished by it. If left to nature, the
foetus will die and decay in utero, come away piecemeal with a horrid
odour, and ultimately the woman will die, a perfect loathing to herself.
1878.]
Harris, The Operation of Gastro-hysterotomy.
333
The danger of hemorrhage in tumour cases is very great, particularly if
the growth lies under the usual, point of incision. In one case reported in
1869 by Dr. Horatio R. Storer, of Boston, he felt obliged to remove the
uterus, to prevent immediate death from loss of blood ; the woman died in
68 hours. In these cases it is often possible to avoid the tumour, by
making the uterine incision as in the operation a hundred years ago,
through the fundus. In the two cases of uterine fibroid in our table, both
women died, one of hemorrhage, and the other of septicaemia : one child
was saved, now eleven years old.
Treatment of the Abdominal Wound.- — Cold water dressing, either by
moistened cloths, or the irrigator, have been used with advantage, and
so has the antiseptic method of Lister. In No. 2 the os uteri being closed,
all the discharges of the uterus escaped for two weeks by the abdominal
wound, two inches of the lower part having been left unclosed for the pur-
pose ; and the parts were cleaned out daily by the use of warm soap-water
injected by a syringe and catheter. Several cases on record were saved,
by reopening the abdominal wound above the pubes, and cleaning out ac-
cumulated discharges and secretions. In cases of occlusion, the parts
should be opened during the operation, and kept so by a drainage tube or
meche.
American Ccesarean Cases, in Territory not belonging to the United
States.
Judging by analogy, we should have supposed that the records of the
West Indies would, like those of the sugar-growing States, have shown
quite a number of operations ; but a careful research fails to bring to light
other than a very few cases. Dr. Benjamin Moseley,1 in his work on
tropical diseases, and the climate of the West Indies, says, " difficult
labours are not common, and children are generally born healthy and
strong, and are not subject to rickets or scrofula."
1. The only Jamaica2 case we have found dates back to 1769, a year
that was remarkable for its Csesarean operations. This, like No. 1 in our
table, was performed with success by a slave-woman upon herself. She
had previously given birth to three children, and appears on this occasion
to have been actuated by a frenzied impatience, and violence of temper, to
obtain relief in the quickest way, without regard to consequences.
She was the property of a Mrs. Bland, a midwife residing near King-
ston, and performed the operation with the hilt of a broken butcher-knife,
cutting at one stroke through the abdominal and uterine walls, and making
a two and a half inch incision into the thigh of the foetus. The child im-
mediately escaped alive, followed by a portion of the intestines, which
latter were returned, the cord tied and cut, and the wound sewed up with-
out removing the placenta, by a plantation midwife. A surgeon was then
1 London, 3d edition, 1803, p. 107.
3 Op. cit., page 108.
334 Harris, The Operation of Gastro-hysterotomy. [April
called in, who re-opened the wound, removed the placenta, cleaned the
intestines from blood and dirt (the operation having been performed on
the ground), and again closed up the wound. In six days the child died
although vigorous when delivered, and in as many weeks the mother was
well enough to be at work. She is reported to have made preparations for"
a second similar operation a year or two later, but was prevented, and
forced to submit to a natural delivery.
From various reports made by Dr. Mosely, it is evident that many
women must have perished in the West Indies, through the wretched
ignorance and superstition of the plantation midwives ; and the bad man-
agement of the crotchet in cases where the foetus presented unfavourably,
or became impacted in the pelvis.
2. 1804.) M. Dariste the elder, performed the operation upon Mrs.
3. 1806.) Achard of St. Pierre, in the island of Martinique, on the
14th of October, 1804, and again on the 29th of October, 180G, with suc-
cess in both instances. Not having access to the report which the opera-
tor made to the Societe de Medecine Pratique de Montpellier,1 we cannot
state the cause of difficulty, and whether the children were preserved or
not, but presume that they were, as the success is said to have been per-
fect.
4. 1820. Dr. John J. U. Van Buren performed the operation upon a
woman with deformed pelvis, April 27, 1820, on the island of Tortula, one
of the Virgin Islands, W. I. The woman recovered, although in her
convalescence she was affected with tetanus. The child was alive when
delivered, but subsequently died.
5. 1822. Dr. Van Buren operated on a case at the same island, on
May 20, 1822, the woman being affected with vascular growths of the
vulva and vagina, which were probably of syphilitic origin. The patient
died of diarrhoea on the sixth day.
6. An operation was performed about fifteen years ago, in Havana, with
success, by M. Godefroy2, a former pupil of the elder Marjolin, of Paris.
7. 1877. Monterey, Mexico. We have written for the particulars of
this case, but have not yet received them. The operation was performed
upon a Mexican woman, and resulted in her recovery. This is the only
instance of the operation we have heard of for Mexico, where pelvic con-
traction and deformity appear to be exceedingly rare, the tendency being,
if anything, in the opposite direction.
We have presented in all, 79 cases of gastro-hysterotomy for North
America, with the recovery of 41 women, and loss of 38. We have heard
of nine more cases for the United States, with six recoveries, and three
deaths, all having been operated upon by surgeons now deceased, but one.
1 Aimales de la Soc. de Med/Prat. de Montpellier, t. 40, pp. 334 and 343.
3 Bulletin de la Societe de Chirurgie de Paris, 2d series, vol. 3, 1862.
1878.] Harris, The Operation of Gastro-hysterotomy.
335
We do not present these in the record, because we have no special points
to offer in regard to them ; but as we have already reclaimed from ob-
scurity a number that were to all intents and purposes lost, we have a
hope that some of them may be secured, especially since we have obtained
the particulars of an operation performed thirty-one years ago, by the
father of the physician who sends the report.
Although we have never had a surgeon decline to send us the report of
a case that had terminated fatally, we can readily see why operators have
in a number of instances failed to send accounts of their cases to medical
journals for publication. A woman with a badly deformed pelvis falls
into the hands of a country midwife, who waits in ignorance for a natural
delivery, until the strength of the patient begins to fail, when she sends for
an obstetrician. He, in turn, tries all sorts of expedients in the hope of
avoiding the resort to the knife. Failing, he summons a surgeon, who, to
prevent the woman dying undelivered, operates, but feels that in all pro-
bability she will not recover. As anticipated, she dies in a few hours or
days, the surgeon feels that he was not at fault, but has gained no honour
because he had not been called in early enough, and allows the case to go
into obscurity. As but two timely operations have occurred in each group
of nine cases, it will be seen how much depends upon the prompt action of
those first called in. And when it becomes generally known, how much
also depends upon an early operation, and how successful such cases have
been in our own country, we shall hear of more elective action, and a
larger proportion of recoveries. Ignorance of 'the past, and fear of fatal
results based thereupon, will never advance a surgical operation, which
appears to be more reluctantly undertaken, than any one in which the
knife is applied. In plain terms, there is nothing in surgery, about which
the surgeon is so timid, as the Cesarean operation ; and nothing in obstet-
rics, of which the obstetrician stands so much in dread. If they were a
little more afraid of the results of cephalotripsy in extremely narrow pelves,
it would be better for some of the women, who might escape death or seri-
ous sequelae by a timely use of the knife. We believe that it is fair to
estimate the general result of American cases, as having saved 50 per
cent, of the women ; and that of the timely operations, at 70 to 75 per
cent, of both women and children.
Every surgeon in our land should make himself fully acquainted with
the steps of, and improvements in, the Cesarean operation, and especially
with the value of operating as early in the labour as practicable, after he
is called in; and every obstetrician should learn the comparative dangers
between craniotomy in contracted pelves, and a timely delivery by gastro-
hysterotomy, as applied to American women.
336 Harris, The Operation of Gastro-hvsterotomy. [April
©
ear.
Locality.
Operator.
6
Colour.
Oause ot
rl i ffif-n 1 tv
1
1822
Nassau, N. Y.
The girl herself ;
14
Quad-
Not any
foetus removed,
roon
and wound
dressed by Dr.
Bassett
1827
Newton, Ohio Dr. J. L. Richmond
White
Vaginal oc-
clusion and
eclampsia
3
1828
O ccoc[uan
A charlatan
25
Mulatto
Occlusion of
Virginia
uterus
4
1832
Near North-
Drs. Dougal and
White
Deformed pel-
u mberland
Van Valzah
vis
Pa.
5
1833
Columbiana
Dr. Robert Estep
23
Bru-
Deformed pel-
Co. Obio
nette
vis
6
1S34
Col u mbiana
Dr. Robert Estep
24
Bru-
Arm pres. and
Co. Obio
nette
def. pelvis
7
1835
Philadelphia
Pa. '
Dr. Wm. Gibson
26
White
Deformed pel-
8
1835
Not stated
Drs. A. Brooke and
31
White
vis
Deformed pel-
T. C. Shreve
vis
9
1837
Carrol Co.,
Dr. John Travis
White
Vaginal oc-
Tenn.
clusion and
rigidity of os
uteri
10
1837
Philadelphia,
Dr. Wm. Gibson
2S
White,
Deformed pel-
Pa. '
2d time
vis
11
1S38
New York
Dr. R. K. Hoffman
42
White
Deformed pel-
City-
vis
12
1838
North of New
A drunken mid-
Black
Not any
Orleans La.
w i f e
13
1810
Hamilton
Dr. Cyrus Fal-
White
Deformed pel-
Ohio
vis
14
1845
Cortland Co.
Dr. Azaria B.
41
White
Pelvic tumour
N. Y.
Shi pin an
15
1815
Fredericks-
Dr. Brodie S.
30
White
Rigidity of os
burg*, "Va.
Herndon
uteri follow-
ing peritonitis
16
1846
Kosciusko,
Dr. Ozias Lewis
25
White
Deformed pel-
Miss.
vis
17
1846
Thibod eaux
Dr. J. A. Scuddav
30
Black
Exostosis of
Co., La.
sacrum
18
1847
Mt. Vernon,
Dr. Wm. H. Bv-
26
White
Exostosis of
Indiana
ford
pelvis
19
1S4S
Knox Co.,
Dr. Joseph Somes
35
White
Deformed pel-
Indiana
vis
20
1849
St. James,
Dr. Thomas Cott-
Black
Exostosis of
Louisiana
man
pelvis
21
1849
Kichmond,
Dr. B. Harvey
Black
Ventral ute-
Miss.
rine hernia,
following
22
1849
Thibodeaux
Dr. J. A. Scudday
33
Black,
Exostosis of
Co., La.
2d time
sacrum
23
1850
Opelousas,
Dr. Vincent Boa-
22
Black
Deformed pel-
Louisiana
gui
vis
24
1850
Near Bethle-
Dr. Benj .Wilhelrn
31
Black
Deformed pel-
hem, Pa.
vis
25
1S51
Perry Co.,
Drs. Schowalter &
18
Black
Narrow and
Alabama
Langhorne
small pelvis
26
1851
Bayou Sara,
Dr. Daniel B.
25
Black
Occlusion of
Louisiana
Gorham
os uteri
27
1852
Wilcox Co.,
Dr. Zacch. E.
31
Black
Impacted
Alabama
Nettles
head
28
1852
Fayetteville,
Drs. Mallett and
21
White
Arm presenta-
N. Carolina
McSwain
tion
Dwarfs.
'Short,"
and full
habit
" Short,'
and lull
habit
4 ft. 6
4 ft. 1
4 ft. 6
4 ft.
3 ft. 6
Dwarf
© ©
Lived
Und'r
2 in.
Und'r
2 in.
3 id.
1*
2 in.
U
3 in.
trans,
3
Cause of death,
woman, etc.
Lived
Died Did well f.-r 10 days:
ate meat with "ci-
der ; result peri-
tonitis. Died
about 12th day.
(Uterus sutured)
Died Peritonitis in 5 or 6
days
Lived
Lived
Lived (Living- at last re-
port)
Died Peritonitis
Died Up and doing well
| on 5th day. Died
on 8th, probably
I of peritonitis
Lived (Uterus united to
old cicatrix)
Lived
Livi
Died Peritonitis. 2d dav
Died Exhaustion, in an
hour
Lived
Died Peritonitis; in a few
, days
Lived
Died On 3d day; prob-
ably peritonitis
Died In 3 days ; cause un-
known
Lived
Died In 3 weeks; " irri-
! tative fever"
Lived
Livedj
Lived
Died Convulsions, and
| exhaustion, in 12
or 15 hours
Lived
Lived
Lived
1878.] Harris, The Operation of Gastro-hysterotomy.
337
' Kesult
© t0
^ I child.
Cause of death of
child.
Twins : Exposure to cold, and
1 dead
prob-
ably
both
Dead
want of care : prob-
I ably both alive
when removed
Cut across the lo
for removal
Condition of woman at
time of operation.
Length of labour
before operation.
Dead Long dead: prolonged
gestation
Dead
Dead
Dead
Lived
Dead
Lived
Lived
Alive
Lived
Lived
Dead
Dead
Lived
Alive
Dead
Alive
Dead
Alive
Lived
Dead
Dead
Dead
Lived
Lived
Dead
Testroyed by cranio-
tomy
Uterine pressure and
decapitation
Uterine pi-essure in
transverse position
(Still living)
Uterine pressure ;
long labour
(Still living, 1878)
Deformed, and soon
died
Uterine pressure ;
long labour
Putrid ; prolonged
labour
Born feeble ; soon
died
Uterine pressure ;
long labour
Died in 3 days ; cause
unknown
Craniotomy ; foetus
12 lbs.
Died in S or 10 days ;
believed from neg-
lect
From effects of long
labour
From effects of long
labour
From effects of long
labour
(Died of fever at 4
months)
From uterine pressure
in transverse posi-
tion
In active natural labour
In convulsions
Exhausted by disease
Exhausted by futile at-
tempts at delivery, and
delay in her giving con-
sent
Exhausted; small rupture
of uterus ; body deliver-
ed ; head in utero
Exhausted
Good ; pulse after opera-
tion SO
Pains vigorous ; pulse 112:
febrile symptoms
Great suffering and ex-
haustion
Pulse 112 before : 96 after-
ward ; soon fell to SS
Pulse good before, under,
and after operation
In natural labour
Strength failing : favour-
able period believed to
have passed
Great exhaustion ; pulse
120
In last extremity ; favour-
ed by utero-abdominal
adhesions
Exhausted
In good condition
Pulse 110 ; face flushed ;
nodes on tibia
Exhausted by labour
Exhausted by labour
Fair; pains strong and
regular
In good condition
Cold ; exhausted ; border-
"ng on articulo mortis
Pains frightfully severe
In convulsions
Feeble, sweating, and ex-
hausted
In fair condition
Fatigued and worn out
A few hours ; one
child born naturally
34 hours
At intervals during
12 or 15 months
More than 24 hours
Long and tedious la-
bour
Long and tedious la-
bour
Before membranes
were ruptured
3i days (midwife)
Over 2 days (midwife)
10 hours ; membranes
entire
24 hours
Less than 24 hours
Less, than 24 hours;
but still much too
long for the strength
of so small a woman
Several days
Irregularly for seve-
ral weeks
Where the case is reported,
N. Y. Med. & Phys. Journ.
1S22, vol. ii. p. 40.
West. Journ. Med. & Phys.
Sci.,1830, vol. iii. p. 4S5.
Am. Journ. Med. Sci., 1S36.
vol. xviii. p. 257.
Am. Journ. Med. Sci., 1S35,
vol. xvi. p. 346.
West. Journ. Med. & Phys.
Sci., 1837, vol. iv. p. 13.
West. Journ. Med. & Phys.
Sci., 1837, vol iv. p. 17.
Am. Journ. Med. Sci., 1S35,
vol. xvi. p. 313.
Am. Journ. Med. Sci., 1836,
vol. xviii. p. 208.
West. Med. & Surg. Journ.,
1842, p. 352.
Am. Journ. Med. Sci., 1S3S,
vol. xxii. p. 13.
N. Y. Journ. Med. & Surg.,
1839, vol. i. p. 214.
N. O. Med. & Surg. Journ.,
vol. xi. p. 13.
West. Med. & Surg. Journ.,
1843, p. 340.
30 hours
12 hours
3 days (2 midwives)
36 hours
Over 24 hours
Several hours
A few hours
Over 2 days
2 days
72 hours (midwife)
4S hours (too much de-
lay on part of opera-
tor)
15 hours
Late operation. Ke-
porter questions its
being justifiable
Am. Journ. Med. Sci., 1849,
vol. xviii., .N. S., p. 122.
Am. Journ. Med. Sci., 1S46,
vol. xii., N. S., p. 3S6.
Communicated by Dr. J. M.
Lewis.
N. O. Med. & Surg. Journ.,
1S42, vol. vi. p. 355?
Western Lancet, 1S4S, vol.
vii. p. 268.
Communicated by the ope-
rator.
N. O. Med. & Surg. Journ.,
1851, vol. vii. p. 337.
N. O. Med. & Surg. Journ.,
1S53, vol. ix. p/772.
N. 0. Med. & Surg. Journ.,
1S50, vol. vi. p. 355.
Communicated by the ope-
rator.
New Jersey Med. Keporter,
1S55, Oct., p. 485.
Communicated by Dr.
Langhorne.
N. 0. Med. & Surg. Journ.,
1852, vol. viii. p. 194.
Communicated by the ope-
rator.
Communicated by Dr. H.
A. Bizzell.
338 Harris, The Operation of Gastro-hysterotomy.
[April
©
Year.
Locality.
Operator.
CO
-I
<
Colour.
29
1S52
Oktibeeha,
Dr. W. H. Merinar
24
Black
Miss.
30
1S53
Centi eville,
Dr. J. W. Craw-
17
Black
Bibb Co.,
ford
Alabama
26
31
1854
Oktibeeha,
Dr. W. H. Merinar
Black,
Miss.
2d time
32 185.3
East ville,
Dr. Wm. G. Smith
25
Black
Virginia
33 1855
Mouterey,
Dr. James L. Ord
30
Mexi-
California
26
can
34
1855
Corning,
Dr. Joshua B.
White
New York
Graves
35
1855
Oktibeeha,
Dr. W. H. Merinar
27
Black,
Miss.
3d t me
36
1856
Richmond,
Dr. Chas. S. Mills
3
Black
Virginia
37
1 S56
Richmond,
Dr. Edward C.
19
Black
Virginia
Drew
38
1856
Wilcox Co.,
Drs. Matheson
in
Black
Alabama
and Gaillard
39
1S57
New Orleans,
Dr.Langenbecker
Black
Louisiana
40
1857
Council
Dr. Wm. F.
20
White
Bluffy Io^a
McLelland
41
1S57
San Francisco
Dr. Elias S.
36
White
California
Cooper
42
185S
Lawrence-
Dr. A. J . bnaner
2 s
\\j v.i
ville, Ga.
43
1860
Florence, Ala.
Dr. James W.
27
White
Stewart
44
1S60
New York
Dr. Fordyce Bar-
38
White
City
ker
45
1S61
Hamburg,
Dr. Isaac J. New-
35
Black
Arkansas
tin
46
1861
Williams-
Drs. J. R. Hicks
40
Black
boro', North
& Wm. F. Hen-
Carolina
derson
47
1S62
Matamoras,
Drs. Cole and
White
Indiana
Sawyer.
48
1S62
St. Louis,
Dr. Chas. A. Pope
32
White
Missouri
49
1S63
Hamburg,
Dr. Robt. M.Dick-
?u
Black
Arkansas
inson
50
1S63
Jefferson City
Dr. J. W. Conway
Black
Indiana
51
1865
Port Wash-
Dr. JohnT.Scholl
38
White
ington, Wis.
52
1S66
Burnt Corn,
Dr. Richard Fow-
35
Black
Monroe Co.,
ler
Alabama
Cause of
difficulty.
Dwarfs, c^j
O
Deformed pel-
vis
Deformed pel- 3 ft. 6
vis
VIS
Vaginal oc-
clusion
Deformed pel-
vis
Deformed pel-
vis
Dwarf
3 ft. 9
Dwarf
6 ?
P3 ?
Deformed pel-
vis
Deformed pel-
vis
Occipito-posr
terior posi-
tion, .and im-
paction of
head
Infantile pel-
vis, with
straight sac-
rum, and
c >tcyx
Impaction of
foetus in
transverse
position
Exostosis of
sacrum
Deformed pel-
vis
Impaction of
foetus
Impaction of
foetus in
transverse
position
Arm presenta-
tion
Deformed pel-
vis
Fibrous pel-
vic tumour
Large uterine
tumour belowi
head of foetus)
Shoulder pre
seutation ;
left dor so-
pubic
3 ft. 2
ro lbs.
U
trans
2^
Lived
Died
Lived
Died
Died
Died
1£
trans.
H
Lived
Died
Died
Died
Lived
Lived
Died
Lived
Died
Lived
Lived
Lived
Died
Died
Lived
Died
Cause of death,
woman, etc.
Exhaustion; 4 hour;
Exhaustion ; 6 day.-
In 6 days; perfora-
tion of vagina and
rectum in 3 places
in an attempt at
craniotomy
Peritonitis ; 4| days
In 4 days ; convul-
sions 2 hours after
a meal of heavy
pastry
Exhaustion ; 36 hrs.
Operation not re-
quired
Peritonitis in 63^
hours
Peritonitis in 97
hours
Exhaustion in 12
hours
Peritonitis
removed
(Irrigator used)
1878.] Harris, The Operation of G astro-hysterotomy. 339
Eesult
to
child.
Dead
Dead
Lived
Lived
Dead
Lived
Lived
Lived
Lived
Dead
Lived
Lived
Dead
Dead
Dead
Lived
Lived
Dead
Dead
Dead
Lived
Dead
Lived
Dead
Cause of death of
child.
From effects of Ions
labour
From effects of Ions
labour
Premature, and
formed
(Living in 1S69)
(Drowned in Dela-
ware when 19)
From effects of lonj
labour
Uterine pressure;
weight 1U pounds
Craniotomy; weighed
9 pounds
Impaction in pelvis
was living in 1871
and in fine health
Impaction in pelvis
Impaction in pelvis
Impaction in pelvis
from rupturing
membranes early,
and giving ergot
Condition of woman at
time of operation.
Pulse 124; exhausted and
feverish
Exhausted by delay
Pains frequent and vio-
lent
Exhausted by fruitless
waiting for nature
Exhausted
Exhausted
Pains frequent and vio-
lent; pulse 80 a few
hours afterwards
In fair condition
3 days (midwife)
30 hours (24 of them
spent in useless de-
lay)
Before membranes
were ruptured
On second day of la-
bour
4 days. (Sacral pro-
trusion mistaken for
foetal head, and per-
forator used upon it
by a young accouch-
eur)
A few hours
Much exhausted
Fair condition
Exhausted by long delay
Exhausted by long labour
and 3 hours craniotomy
Exhausted by long labour
— delicate health
(9| pounds in weight); Pulse 120 before, and 134
(Not stated
ably)
prob-
( Alive Nov. 1877)
Uterine pressure ;
membranes ruptur-
ed almost with first
pain
to 140 after the opera-
tion ; nodes on shins
In good condition
Fatigue and exhaustion
Fatigue and exhaustion
Length of labour
before operation.
4^ hours
2 or 3 days
Early operation
61 hours. (No attempt
to use forceps, or
deliver by cranioto-
my, although head
was in siyht during
a pain, for 2C hours)
42 hours. (Much time
lost in fruitless ef-
forts)
30 hours under mid
wife ; operation se-
veral hours later
Much exhausted
Strumous habit, and af-
flicted with intermittent
fever
Exhausted : waters long
evacuated, anaemic from
loss of blood
2 days
6 or S hours. (No de-
lay)
On 4th day of labour
Late. (Under mid-
wife)
26 hours (under mid
wife)
14 hours
60 hours. (Podalicand
cephalic version
failed ; arm remov-
ed, evisceration of
body and chest at-
tempted)
Where the case is reported.
Phila. Medical Examiner,
1854, vol. x. p. 587.
Trans. Med. Assoc. State of
Ala., 1854, p. 75.
Phila. Med. Examiner, 1854,
vol. x. p. 587.
Virginia Med. Journ., 1S56,
vol. vii. p. 203.
Communicated by Dr. T.
M. Logan.
Phila. Med. & Surg. Eep.,
1869, Dec, p. 375.
Charleston Med. Journ. &
Rev., 1S56, p. 172.
Monthly Stethoscope, Rich-
mond, Va., 1856, p. 434.
Communicated by the ope-
rator (1877).
Communicated by Dr. A.
C. Matheson.
N. O. Med. News and Hosp.
Gaz., 1857, p. 555.
Bost. Med. & Surg. Journ.,
vol. v. p. 4S4.
Pacific Med.& Surg. Journ.,
March, 1858, p. 89.
Atlanta Med. & Surg.
Journ., Oct. 1859, p. 65.
Nashville Med. & Surj
Journ., 1S60, p. 501.
Am. Med. Times, N. T., vol.
i. p. 361 ; vol. ii. p. 55.
N. O. Med. & Surg. Journ.,
vol. xviii. p. 305. Parti-
culars by letter from the
operator.
Communicated by Dr. Robt.
J. Hicks (1S77).
Communicated by Dr. C. S.
Arthur.
Communicated by Dr. Wm.
S. Barker.
Cincinnati Lancet & Obs.,
1S63, vol. vi. p. 401.
Communicated by the ope-
rator (1877).
Southern Journ. Med. Sci.,
New Orleans, 1867, vol.
i. p. 633.
340
Harris, The Operation of Gastro-hysterotomy. [April
Locality.
53 1866 West Chester
Co., N. Y.
1867
1867
1867
186
1S6S
1869
1869
1869
1869
1S70
1870
1871
1875
1876
Pittsfield,
Mass.
Richmond,
Virginia
New Haven,
Connecticut
New Orleans,
Louisiana
Mobile,
Alabama
Aberdeen,
Mississippi
Philadelphia
Pa.
Edgefield,
S. Carolina
Ann Arbor,
Michigan
Baltimore,
Maryland
Kingsbridge,
New York
Portland,
Maine
Albany,
New York
Fond du Lac,
Wisconsin
Portsmouth,
Ohio
Saginaw City
Michigan
Operator.
Dr. G. J. Fisher
Dr. Wm. Warren
Greene.
Dr. Chas. S. Mills
Dr. T. Beers
Townsend
1876 Scottsburg,
Indiana
Detroit,
Michigan
Summary
Drs. D'Aquin and
Brickell
Dr. J. T. Gilmore
Dr. E. Paul Sale
Dr. Walter F.
Atlee
Dr. J. Walter Hill
Dr. Abram Sager
Dr. James W.
Butler.
Drs. Paluel de
Marmoti and C.
F. Rodenstein
Dr. T. A. Foster
Dr. J. V. L.
Quackenbush
Dr. E. L. Griffin
Drs. Jones and
Kline
Dr. 0. P. Barber
Dr. Wm. N.
McCoy
Dr. Edward W.
Jenks
Colour. Cause of
difficulty.
Black Arm presenta-
! tion ; impac-
tion ; pelvic
brim con-
tracted
Black
Black
Black
French
Creole
Black
White
Deformed pel-
vis
Deformed pel-
vis
Deformed pel-
vis
Occlusion of
vagina and os
uteri
Deformed pel-
vis
Black Extra and in-
tra uterine
pregnancy
Deformed pel-
vis
Black
White
White
White
White
White
White
White
White
White
Almost com-
plete occlu-
sion of vagi-
na ; examined
per rectum
Small and de-
formed pelvis
Deformed pel
vis
Deformed pel
vis
Eclampsia,
with constric-
tion of uterus
Deformed pel
vis
Sub-peri-
toneal uterine
fibroid
Exostosis of
sacrum
Deformed pel
vis
Rigidity of os
uteri, and con
traction of va-
gina, from in-
flammation
and adhesions
Armpreseut'n
& def. pelvis
Dwarfs.
3 ft.
Und'r
2 in
Dwarf
3 ft. Hi
115 lbs.
3 ft. 4
65 lbs.
2 in.
2*
trans.
2£
g =
2 g
Cause of death,
woman, etc.
Died Exhaustion in Z\
days, following
fright and excite-
ment. No bad
symptoms, for 3
days
Lived
Died
Lived
Lived
Died
Died
Died
Lived
Died
Died
Died
Died
Died
Died
Lived
Died
Died
Lived
Pre-existing entero-
peritonitis, in 5
days
{3 fine hemp uterine
suture*) 5 uterine
vessels tied
(0 silver-wire su-
tures in uterus.)
Well, Nov. 1&77
Peritonitis, in 60
hours
Septicaemia, 5 days
Obstruction of bow-
els ; probably in-
closed in uterine
wound
(Carbolic acid and
glycerine) dress-
ing to wound ;
complete union by
eleventh day
Secondary shock in
20 hours (4 silver
uterine sutures)
Peritonitis in 3 days
Metro-peritonitis in
42 hours (1 uterine
suture used)
Briyht's disease in
60 hours : forceps
and turning could
not be used (10
silk uterine su-
ture?)
Peritonitis in 72
hours (2 silver
uterine sutures)
Hemorrhage and ex-
haustion shortly
after operation (1
silk uterine su-
ture used)
(1 silk uterine su-
ture)
Peritonitis and de-
generation of ute-
rine tissue in 5
days (3 silver ute-
rine sutures)
Died in 33 hours,
from vomiting on
her back, and in-
haling the matters
thrown up.
Weighed over 200
lbs. 5 feet 2 inches
in height.
(4 silver uterine su-
tures used)
Peritonitis, 17
Exhaustion, 6
Convulsions, 3
Hemorrhage, 1
Septicaemia, 1
Obstructed
bowels, 1
1878.] Harris, The Operation of Gastro-hysterotomy.
341
6
&
Eesult
to
child.
1
Cause of death, of
child.
Condition of woman at
time of operation.
Length of labour
before operation.
Where the case is reported.
53
Dead
Uterine pressure
Much prostrated
After exhaustion
Communicated by the ope-
rator.
.54
Lived
26 hours
Bost. Med. & Surg. Journ.,
1868, vol. L, N. S., p. 1.
Communicated by the ope-
rator.
55
Dead
Premature and de-
formed
Affected with dysentery;
5 months pregnant
Nearly 2 days
56
57
58
59
60
Lived
Dead
Dead
2, lived
Lived
Craniotomy
Uterine pressure
(Was alive and well
a year ago)
Pains infrequent, and not
violent ; pulse 130 to 160
for first 5 days after ope-
ration
Countenance anxious; re-
spiration 26 ; pulse 143 ;
no uterine action
Respiration 37; pulse 135,
small aud weak; tem-
perature 97^°; exhausted
Favourable
621 hours
10 days. (5 under mid-
wife)
Over 2 days
Extra-uterine pains
for more than two
weeks
A few hours ; mem-
branes entire
New York Medical Record,
1868, p. 1.
New Orleans Med. & Surg.
Journ., 1S6S, vol. xxi. p.
454.
Communicated by the ope-
rator (1871).
N. O. Med. & Surg. Journ.,
1870, vol. xxiii. p. 727.
Am. Journ. Med. Sci., April,
1870, p. 393.
61
Lived
Exhausted ; woman had a
recto-vaginal fistula
56 hours
Communicated by the ope-
rator (1S71).
62
(33
64
65
Lived
Dead
Lived
Alive
(Died when 6 weeks
old)
Craniotomy ; partly
decomposed
(Died in a few days ;
presumed from ure-
mic poisoning)
Weak, and had always
walked with crutches
Almost hopeless
Much exhausted
In convulsions
S or 9 hours ; mem-
branes entire
Long labor (midwife)
44 hours. (23 hours
delay in procuring
assistance)
Irregularly for 2
weeks
Communicated by the ope-
rator (March, 1871;. Mich.
Univ. Med. Journ., Sept.
1871, p. 385.
Journ. Gynsecol. Soc, Bos-
ton, vol. iii., July, 1870,
p. 44.
Med. Gaz. & Weekly Rev.,
N. Y., 1870, p. 136.
Trans. Maine Med. Assoc.,
1868-69, p. 273.
66
Dead
Craniotomy
Much exhausted
3 days (midwife)
Communicated by the ope-
rator (Dec. 1871).
67
Dead
Probably pressure;
was putrid
Much exhausted
Never had distinct la-
bour pains ; had
gone a month over
her time
Communicated by the ope-
rator (1872).
0 _>
69
70
Lived
Lived
Lived
(Alive, July, 1S76— 6
months — weighed 6
pouuds, and mea-
sured 20 inches at
birth)
Exhausted
In convulsions
ob nours
Early operation
2i days
The Clinic, Cincinnati,
Aug. 1875, vol. ix. p. 64.
Detroit Rev. Med. & Phar.,
Sept. 1876, p. 611.
American Practitioner, Oct.
1876, p. 220.
71
Dead
(Appeared not to have
been long dead)
Worn out from length of
labour
7 days in charge of
women, then a mid-
wife for a short time
Am. Journ. Obstetrics, Oct.
1877, p. 606.
Alive 37
Timely operations 16
Women saved . 12
Children saved . 13
Cases obtained by corre-
spondence, 20.
Liv'd32
Dead 36
342 Smith, Clinical Observations upon Reflex Cough. [April
Postscript Case No. 72. After our tabular statement had been put
into type, we found recorded in the Archives de Tocologie of Paris for Jan.
1877, an operation which was performed in May, 1875, in Toledo, Ohio,
by Dr. Lungren, and reported to the said journal through Dr. H. Cazin,
of Boulogne-sur-mer. The case is a remarkable one, in illustration of the
opinion we have advanced in regard to the value of an early operation,
and the importance of using silver wire sutures to check excessive hemor-
rhage from the uterine wound.
The woman was 29 years of age, white, the wife of a tailor, and had
been the subject of rickets in infancy, by which her pelvis was much de-
formed, the conjugate diameter of the superior strait being computed at
2^ to 2^ inches, and the contraction of the inferior, forming an additional
obstacle to the use of instruments. As this condition was fully determined
some time before the operation, the knife was resorted to as early in the
labour as was considered advisable, pains having existed at intervals for
seven hours. The patient was placed under the influence of chloroform,
and incision made in the median line : the hemorrhage from the uterine
wound, being excessive, was arrested by four silver wire sutures, which
were twisted twice, cut off near the second turn, and bent down at a right
angle over the incision. The abdominal cavity, being carefully cleansed
of blood, was closed, and the wound dressed according to Lister's method
The patient made a rapid recovery, and with no bad symptoms at any
time, her highest pulse being 100, and temperature 100|-. She and her
child were alive and well a year afterward.
This case increases the number in which uterine sutures have been used
to 12, and recoveries to 5, with the general result of 35 saved, to 37 lost.
In three of the five recoveries, silver sutures were used, the women are
living, and have suffered no inconvenience from their presence.1
713 Locust St., Philadelphia, January 21, 1878.
Article II.
Some Clinical Observations upon Reflex Cough. By A. A. Smith,
M.D., Lecturer- Adjunct upon Clinical Medicine at the Bellevue Hospital
Medical College, New York.
The proper title of this paper would have been " Clinical Observations
upon Reflex Cough, the primary seat of irritation being outside of the
respiratory tract." I have not included the discussion of the question as to
whether cough, dependent on irritation in the respiratory organs, is reflex,
even though that irritation be at some point remote from the vocal cords.
1 Headers of this journal will greatly oblige the author, by sending to him any un-
reported cases that may be known to them, or filling up any gaps that may exist in the
tabular record of operations.
1878.] Smith, Clinical Observations upon Reflex Cough.
343
I am fully aware that "reflex influence" is often made a cloak to cover
much ignorance as to the etiology and pathology of certain manifestations.
Neuralgias and paralysis are often referred to " reflex influence" when it
is not always an easy matter to discover the original seat of irritation. I
admit that it is a very difficult, problem in the physiology of the nervous
system to distinguish between the phenomena of purely reflex action and
those of consciousness and intelligence ; still more difficult is it in the
pathology. Careful clinical observation will aid us very much in solving
many of these problems. During the past few years there have come
under my observation a number of cases in which the cough seemed to be
due to reflex influence, and in almost all, if not all, the primary seat of
irritation was easily recognized. They have all occurred in private prac-
tice, and some of them have been seen by me in connection with Dr.
Fordyce Barker.
Case I — Baby M., a male child, four weeks old, began to cough vio-
lently one night suddenly, and to cry each time he coughed. At flrst the
cough seemed to be paroxysmal. Up to this time he appeared to be per-
fectly healthy. When called to see him I failed to discover an adequate
cause to account for the cough, and, as there was some tendency to con-
stipation, I ordered to be given him the traditional teaspoonful of castor
oil. The following day I found, although the oil had acted quite freely,
the cough was not relieved. On the contrary, it seemed to be worse. A
most careful examination of the lungs, heart, and throat still failed to find
the cause. There was no febrile movement. The second, third, and
fourth days passing and still the violent and persistent coughing con-
tinuing, I asked that he be stripped of every article of clothing. I was led
to do this because with each paroxysm of coughing he seemed to have
pain of a different character from that which we get evidence of if the
pain is in the thorax. As he was lying on the bed, after being stripped,
I observed that each time he coughed there was an umbilical protrusion,
I put a small compress over it, and held it with my hand. As long as
this was done there was no coughing; but as soon as it was removed, the
original programme was repeated. I then placed a compress on, and held
it in place with adhesive plaster, as is done in umbilical hernia. The
cough and its accompaniments ceased as by magic. At the end of a
week, thinking to test the matter of cause and effect, I removed the com-
press, and the paroxysms of cough returned. I left it off' during the day,
and the paroxysms continued. That night I replaced the compress, and
the paroxysms ceased. I was now quite convinced that the cough and
the pain were due to the umbilical protrusion ; but, as if to make the his-
tory complete, a few nights later the child, after being quite restless,
awakened, and soon had the paroxysms of coughing and crying again.
The nurse removed the clothing, and found the compress had become
loosened and had dropped off". She replaced it, and there was no more
cough.
Case II — A. McM., aged two and a half years, came under my care
during the temporary absence of the physician of the. family. She had
always been healthy, but for two days before I saw her she had lost appe-
tite, had some nausea and vomiting, and was very restless at night ; had
some cough, and complained of slight abdominal pains. Examination of
3U
Smith, Clinical Observations upon Reflex Cough. [April
lungs and heart failed to reveal any disease. On the posterior wall of the
pharynx there was a collection of mucus, and the tonsils were enlarged.
Thinking the cough was caused by the condition of the throat, I ordered
an astringent application to be used, directly applied night and morning,
and prescribed a simple laxative powder to be given at night. The next
day she was somewhat better, but on the fourth day I was called again to
find the child with a cough almost constant, a temperature of 103° F.,
pulse 120, and very restless and uneasy. There was no crying at the
time of coughing. A careful examination again failed to reveal a cause.
I was puzzled. The child remained in much the same condition the three
following days despite all my treatment, when the riddle seemed to solve
itself ; for on this third day, the seventh since I had first seen her, she
passed a large peach-stone, and her cough, elevation of temperature, and
restlessness, all ceased within a few hours, and there was no return of
them. This child, during the few hours before she passed the stone,
showed some tendency to a convulsion, which probably would have de-
veloped had the stone remained much longer as a source of irritation.
Case III — W., a female child, aged four, after suffering for two days
from what seemed to be an attack of indigestion, began to cough, not vio-
lently at first, but the violence increasing, she was brought to me for
advice. She was somewhat anaemic, digestion poor, tongue coated, rest-
less at night, and indisposed to play as formerly. There was complaint of
slight abdominal pains occasionally. There was no elevation of tempera-
ture at the time of consultation. Thinking I discovered evidence of
periodicity in the attacks of coughing, I ordered a quinia and anodyne
cough mixture, with directions to return in one week. At the end of
that time there was slight improvement. Ordered treatment continued.
At the end of the second week, however, she was worse again. Another
examination of her suggested to me possibly the presence of worms in the
intestines. I gave her santonin gr. ij, night and morning for four days,
and on the evening of the fourth day five grains of calomel, with the re-
sult of bringing away the next day an enormous quantity of the "ascaris
vermicularis," and with this escape the cessation of the cough — and, in-
deed, of all the unpleasant symptoms. The child rapidly improved, and
became well and strong.
Case IV M., female child aged six, had never had any pronounced
illness but was never considered a robust child, was always pale and thin
and of a nervous temperament. As a baby she was subject to attacks of
indigestion. From the third to the fifth year she was comparatively free
from these attacks. In her fifth year, during the summer, she had some
peculiar attacks, characterized by pain in the abdomen, distension and
diarrhoea and violent cough and sometimes vomiting. These attacks would
last four or five days and then pass off, and she would be quite well again.
The first attacks occurred in June. She came under my care the following
November. For the three months preceding, there had been almost
constant cough with progressive loss of flesh, strength, and appetite, night
sweats, pains in the chest, and dyspnoea, no expectoration, the attacks of
diarrhoea occurring at intervals of two or three weeks. An examination
of the heart, lungs, and throat failed to reveal a cause for all this disturb-
ance. Treatment availed but little. Two weeks after she came under
observation she passed several sections of tapeworm. Appropriate treat-
ment removed the remainder of it, which was followed by complete cessa-
tion of all her disturbances.
1878.] Smith, Clinical Observations upon Reflex Cough.
345
Case V. — Mrs. M., aged 25, consulted me in September, 1875, for the
relief of a cough which she had had for a month. She had been out of
the city for the summer, and had just returned the day before. The cough
seemed to be increasing, and alarmed her. She had noticed that it was
dry, and that it was worse every other day. Having prescribed for her
during the previous year for malarial symptoms, and failing on examina-
tion to find any disease of the lungs, heart, or throat, I again gave quinia,
thinking the cough was malarial in its origin. I saw her several times
between this and the middle of October, but much to my discomfort, and
still more to hers, I did not seem to make much progress in relieving her
cough. About the middle of October there were added other symptoms,
loss of appetite, flesh, and strength, disturbances of digestion, headache,
anaemia, some dyspnoea on exertion, and some thoracic pain, particularly
on the left side. By Nov. 1 all these symptoms seemed progressing except
the cough, which remained about the same as when I first saw her % there
was no expectoration. She had lost in weight since the middle of August
about sixteen pounds. I intenogated every organ in the body, and failed
to make a diagnosis satisfactory to myself. I could not but believe that
some serious organic disease was advancing, and that I was unable to dis-
cover its seat. On the morning of Nov. 2 she brought to me in a bottle
some sections of tapeworm, which she had passed that morning. I at
once put her on appropriate treatment. She got rid of her tapeworm, and
was then put on tonics, and by New-year's day she had nearly regained
her former health and vigour. I confess, as I did to her at the time, that
tapeworm, as a cause of her trouble, had not occurred to me until I saw the
sections she brought me ; and even then I did not feel convinced until I
eaw the rapid and marked improvement in her condition after its removal.
Case VI — Mrs. M., aged 23, began to cough violently in April. When
I was called to see her she said, " Doctor, I believe I am enceinte again,
because I have now just such a cough as I had when I was in that con-
dition before." This was her second pregnancy, and her belief proved to
be correct, for she was confined the following January. The cough con-
tinued during the first two and a half months of pregnancy and then ceased^
just as it had done in the previous one, and an examination of the heart,,
lungs, and throat gave negative evidences. There was at no time any morn-
ing sickness, the cough probably taking the place of it. There was no ex-
pectoration. Thinking it was reflex, I prescribed bromide of sodium, five
grains, four or five times a day, with the effect to relieve it very much.
Case VII. — C, female child, aged three and a half, had gone to bed
feeling quite well. At one o'clock her mother was called by the nurse to
see her, saying she had " croup." She found her coughing almost con-
stantly, with great dyspnoea, the cough " croupy." Having had an attack
of the kind before, and having been relieved by an emetic, the mother at
once administered a teaspoonful of syrup ipecac. In a few minutes she-
threw up an enormous quantity of food, and among other things some meat
she had eaten thirteen hours before, not a particle digested. At two and
a half she was entirely relieved of the cough and dyspnoea. She slept
quietly the remainder of the night, and the next morning there was but
little trace of the previous night's disturbance. She had several very sim-
ilar attacks afterwards, always due to indigestion, and always relieved by
an emetic. Such cases as this are quite common.
No. CL April 1878. 23
346 Smith, Clinical Observations upon Reflex Cough. [April
The following case is unique : —
Case VIII. — Mr. S., aged forty-five, a large man of rather a nervou-
temperament and a good liver, subject to attacks of asthma the past
twenty years. He has been under my professional observation the past
four years. While visiting him socially a short time since, he said : "I
want to call your attention to a peculiar feature of my case." He stripped
to the waist, and showed me a small growth on the back. It was the size
of a split pea, situated about two inches to the right of the spinous process
of the second dorsal vertebra. It was not painful even when pinched, as
a neuroma is. On scratching this he at once began to cough and to suffer
from dyspnoea, and to be very nervous and uneasy. His wife had discov-
ered this feature years before while rubbing his back during one of his
attacks of asthma. As she rubbed rather forcibly over this growth, the
phenomena as above described occurred. This case would seem to add a
new argument for considering asthma an essentially nervous disease. I
examined his chest before and during the scratching, but did not find
that during the scratching there was any change in the physical signs.
Case IX — Miss S., aged 19, suffering from a retroverted uterus and
spinal anaemia with all its accompaniments, was treated with electricity
along with other remedies. Usually galvanism was used. One pole of
the battery was placed on the cervical spine, and, as the other was passed
on either side of the spinous processes of the last dorsal and first two
lumbar vertebrae, she began to cough, mildly at first, but violently if the
application was continued. The current was not of sufficient strength to
give pain at these points. The faradaic current produced the same phe-
nomena, but not in so marked a degree. If the second pole was placed
along any of the other spinous processes, no such effects wyere produced.
The attacks of coughing would cease immediately the electricity was
stopped. The patient was of a very nervous temperament, and quite
hysterical.
Case X — Mrs. W., aged 36, married, the mother of one child, had
suffered for over a year from a cough, which had always been considered
nervous in its origin. An examination of the heart and lungs gave no
evidence of disease. On the posterior wall of the pharynx there was fol-
licular inflammation, with considerable mucus. Thinking this might
account for the cough, and especially as she was quite anaemic and suffered
from an impaired digestion, I ordered a tonic, and gave her also an astrin-
gent application to be applied to the pharynx twice daily. In the course
of two weeks she was much relieved, but still the cough continued suffi-
cient to annoy her. I saw her several times in the following two
months, and, although her general condition improved, she did not get en-
tirely relieved of the cough. One day about three months after I first
saw her, I was hastily summoned to her, and found her lying on a lounge
suffering from a severe pain in the back, unable to move without increas-
ing it very much, and with a cough which was almost continuously parox-
ysmal. I learned that, in attempting to reach a book on a high shelf, she
felt as though something gave way in her back, and immediately the
severe pain and the peculiar cough occurred. I at once made an exami-
nation, found a retroverted uterus, replaced it with very little difficulty,
with the result of not only relieving the pain, but also, to a great extent,
the paroxysmal cough. I then obtained the history that the " nervous
cough" was aggravated at the times of menstruation, particularly at the
beginning of it, and when the flow became fully established the cough
1878.] Smith, Clinical Observations upon Reflex Cough. 347
almost ceased. An Albert Smith pessary was introduced in the course
of a few days, with the effect of relieving the unpleasant symptoms accom-
panying the retroversion, and of entirely curing the cough. Subsequently,
thinking she might do without the pessary, it was removed; but the
retroversion recurred, and with it the cough. Again the pessary relieved
the retroversion and the cough. I regard this case as one of partial retro-
version when I first saw her, and of complete, or nearly so, when she
made the extra muscular effort to reach the book.
In Le Lyon Medical for November, 1876, there is reported an inte-
resting case bearing on this subject.
A married woman, 23 years of age, had been treated for a long time for a
nervous cough without success. She had been pregnant at the age of 21, but
had aborted at the third month. After that time she suffered, from leucorrhcea
and lumbar pains, which were augmented by standing or walking. The cough
occurred only during the day, and consisted of frequent short paroxysms, with
intervals of repose varying from half an hour to two hours. The cough ceased
immediately on lying down. An examination revealed an anteverted and con-
siderably enlarged uterus. In the dorsal decubitus the organ resumed very nearly
its normal position. The uterus was replaced, and kept in place by a pessary,
and the cough ceased at once. A few days later the pessary was removed, the
displacement returned, and with it the paroxysms of coughing, and these parox-
ysms continued until the pessary was reapplied. It is stated that at the end of a
a year the patient was so much improved that even the removal of the pessary
produced no return of the cough.
Case XI A female child, aged seventeen months, after two days of
uneasiness, loss of appetite, irritability, and restlessness at night, began to
cough, and at the same time to have some febrile movement. I saw the
child on the morning of the third day. She had then been coughing
twenty-four hours, and had awakened the previous night several times,
crying out as though in pain, and coughing quite violently. I failed on
examination to find anything in the throat or thoracic cavity to account
for the cough. An examination of the mouth revealed the gums much
swollen, and very tender over the upper canines. I lanced them freely,
and gave no other treatment. The relief seemed to be immediate. There
was but little coughing that day; she had a good night, and the following
day she seemed entirely well. About three weeks subsequently I was
called to see her again, and obtained about the same history as before. An
examination revealed the gums swollen and tender over the lower canines.
The lancet again gave relief to all the symptoms. Any treatment which
would have allayed the irritation of the gums would probably have relieved
the cough. This is one of a class of cases in which the bromides, from
their well-known power of allaying reflex irritation, give such relief.
Oftentimes the bromides will allay the cough in both children and adults,
but especially the former, because of their more easily impressed nervous
systems, and for this reason more liable to reflex cough, when the seat of
irritation producing the cough is unrecognized.
Cases similar to some of those included in this paper are probably fami-
liar to most physicians. The cough of teething is recognized often even
by the laity. The cough due to disturbances in the alimentary canal, to
ovarian and uterine irritation, has frequently been referred to ; but in the
cases I have here reported, the relation of cause and effect was so appa-
rent that I have included some that would seem almost commonplace.
548 Smith, Glycogenosis and Bright's Disease. [ April
In Cases IV. and V. there was the clinical history apparently ol progres-
sive pulmonary disease: cough, loss of flesh, strength, and appetite, and, as
the anaemia advanced, there were in both cases dyspnoea, night sweats, and
thoracic pains. These pains were probably due to intercostal neuralgia.
In both cases there was at times febrile movement. All these symptoms
disappeared when the cause (the tapeworm) was removed.
The cause of irritation is not always so easily discovered. It is quite
common to hear of a "nervous cough," a hysterical cough. Is it not pro-
bable that in many such cases there exists a cause, remote perhaps from
the larynx, which can with care be discovered and removed, and thus the
cough, as well as many other of the nervous and hysterical manifestations,
be relieved?
Cough is frequently an accompaniment of what is called spinal irritation.
The cough due to reflex irritation is not the same in character in all
cases. Generally it is dry. In some it is paroxysmal ; in others almost
like the sharp, quick bark of a small dog; but I do not believe it is suffi-
ciently characteristic to enable one to recognize it simply by its peculi-
arities.
Article III.
Derangement of the Glycogenic Function of the Liver as a Cause
of Bright's Disease. By Gouverneur M. Smith, M.D., Physician to
the New York and Presbyterian Hospitals.
Investigations relating to the etiology of Bright's disease have, within
a few years, been prosecuted with special care. Such investigations have
proved of great practical utility. In the first place, they have enabled
physicians, to a certain extent, to guard against the prevalence of a malady
which is of frequent occurrence in this latitude, and which is dreaded on
account of its mortal character. In the second place, such studies have
enabled medical men to treat the disorder in a more satisfactory manner,
and when patients have been relieved of their more distressing symptoms,
and are able to resume the ordinary duties of life, they can often be placed
under circumstances tending to prevent further injury to the renal tex-
ture.
The term Bright's disease is employed in such a manner that it includes
diverse pathological conditions of the kidneys. Each structure entering
into the composition of the renal emunctories is liable to morbid changes.
Such changes may be confined primarily to one structure, other structures
becoming subsequently involved, or there may be apparently a contempo-
raneous morbid eruption, involving all the tissues, the initial lesion escap-
ing observation.
1878.]
Smith, Glycogenosis and Bright's Disease.
349
It is a well-recognized fact, as shown by post-mortem examinations, that
very different diseased appearances of the kidneys are observed in the
bodies of those succumbing from renal dropsy, and it is possible that the
causes of these diverse conditions nftiy have been as different as are the
lesions which are discovered. At the same time, it must be admitted that
combined causes may have been operative in producing complex lesions,
and, again, diverse causes may be provocative of a like lesion.
It may seem unscientific to group together heterogeneous lesions and
classify them under one disorder. In time, this group of morbid pheno-
mena will be dissected into accurate subdivisions — each subdivision being
as distinctly recognized by name as is the distinct nomenclature now em-
ployed to designate the group. No apology seems absolutely necessary,
however, as yet, for the continued use of the term Bright's disease, which
has become so universally employed, for while it is often inferred under
what kind of a renal lesion a patient is suffering, nevertheless in most
forms of lesions of the kidneys, to which special allusion has been made,
while there may be distinctive signs of each lesion, there is still, owing
to the interruption of the renal functions, such an analogy of symptoms as
to still warrant a generic term to express them.
The design of this article is to call attention to a special point in the
etiology of renal dropsy, viz., derangement of the glycogenic function of
the liver as a cause of B right's disease. Now, in order to illustrate this
subject, it appears to me desirable to review, in a brief manner, the causes
of Bright's disease ordinarily recognized, and "to review some points relat-
ing to hepatic sugar formation. In doing this I must be pardoned if refer-
ence is made to my former investigations on these subjects, which refer-
ence will partially explain how a novel cause of a renal malady has more
recently been suggested to my mind.
In a paper read before the New York Academy of Medicine, April 1,
1869, and published in Volume III. of the Academy's Transactions, I
endeavoured to illustrate the etiology of Bright's disease by an analysis of
three hundred and eight cases of the disorder occurring in the New York
Hospital. The limits of this article will not allow of a full review of all
the points brought forward therein, it must suffice to allude to a few of
them as introductory to the subjoined thoughts.
In regard to the causes of acute Bright's disease, or tubal nephritis as it
has been denominated, the following causes were alluded to: exposure to
cold and wet, and checking perspiration, sequel of measles, of scarlet fever,
and of malarial fever, immoderate alcohol drinking, obstructions to the
escape of bile, an irritable state of the urine as occurring in various dis-
eases, and the internal administration of turpentine, cantharides, arsenic,
etc.
Respecting the chronic form of Bright's disease in a considerable pro-
portion of the two hundred and sixty-eight cases before alluded to, the
350
Smith, Glycogenosis and Bright'.-, Disease.
[April
causes were apparently assignable, and these mar be enumerated as fol-
lows : intemperance, climatic exposures to the inclemencies of the weather,
malarial poisoning, workings in lead, opium habit, gout and rheumatism,
diseases of the heart, while a number of patients had suppurating sores.
Dickinson, in his admirable treatise on albuminuria, says: —
"The following are the conditions to which granular degeneration of the kid-
neys can be traced : —
" 1st. Conditions which produce and maintain venous congestion of the kidney,
such as valvular disease of the heart and pregnancy.
" 2d. The gouty habit, from whatever circumstance it arise, but more especially
when it is associated with lead.
"3d. A general tendency to fibroid degeneration, as shown bv changes in the
liver, lungs, and other organs.
"Further, it must be allowed that the disease arises in certain cases in conse-
quence of a local tendency peculiar to the individual, or as a result of influences
of which as yet we know nothing."
Concerning the amyloid kidney, or " depurative infiltration," as it has
been denominated, it is constantly associated with cancerous, syphilitic,
and tubercular diseases, and indeed .with other disorders, accompanied by
profuse suppuration, other viscera besides the kidneys being similarly and
s i m ul tan eou sly aflfe c ted.
At this stage, attention is particularly called to a special point. Dick-
inson has shown, in speaking of albuminuria, that " arctic cold and equa-
torial heat are equally inimical to its development. It chiefly abounds
where the mean temperature of the year is not far removed from 50° F."
My study of this subject as relating to this Continent, and as shown in the
paper before alluded to, seemed to corroborate this opinion.
In comparing the mortuary tables of widely scattered localities in our
section of the northern hemisphere, it was found that Bright's disease was
most prevalent in regions where the seasons are most marked, and where
the vicissitudes from heat to cold are often abrupt and intense. If such
climatic causes can induce chronic congestion, and ultimately organic
lesions in the kidneys, it can be legitimately inferred that other causes,
which lower the tone of the system and which induce a pretty constantly
diminished temperature of the body, can produce similar results.
Here a digression must be made, in order to fully understand the con-
clusions arrived at in this article.
After looking into the subject of Bright's disease, my attention was di-
rected to that of diabetes, and in a paper on that disorder, read before the
N ew York Academy of Medicine, Feb. 2d, 1871,1 I took occasion to present
some novel views regarding the uses of hepatic glycogenesis. Subse-
quently to this time, viz., on June 15th, 1871, Dr. Dalton read a paper
before the Academy on sugar formation in the liver, and by request I took
part in the discussion, and confined my remarks to the "Uses and Derange-
ments of the Glycogenic Function of the Liver."2
1 Transactions New York Academy of Medicine, vol. iii.
3 Ibid., New Series, vol. i.
1878.]
Smith, Glycogenesis and Bright's Disease.
351
The physiologists up to this period had directed their investigations
strictly towards deciding the question whether or not the liver possessed a
glycogenic function, and had not, so far as I am aware, made known any
very specific uses for the function. 'It seemed to be proved by the experi-
ments of Bernard, Flint, Lusk, and Dalton, that sugar was generated by
the liver, and could readily be traced from this viscus to the right side of
the heart ; that the blood of the general circulation contained but a small
quantity of sugar, but in the right side of the heart it occurred in a double
or quadruple quantity as compared with that found in the jugular %ein.
From these facts it appeared to me a legitimate inference that such a
constant and normal hepatic glycogenesis must have a benign purpose in
the economy, and, further, that, as a function, it must be as liable to de-
rangement as are the other functions of the animal economy. The liver
might generate the sugar either too freely or too sparsely, or might en-
tirely fail to create it ; or, again, an abnormal form of sugar might be elabo-
rated, or some material which is not sugar, and which, though perhaps
allied to it, is a diseased product, and foils to supply the economy with a
material susceptible of being utilized in a healthful manner. An increased
amount of sugar as occurring in the disorder known as diabetes had long
been recognized and made an object of investigation ; but respecting these
other points no researches, so far as my observation extended, had been
made.
A brief epitome of some of the views relating to these topics, which I
have before offered on the occasion alluded to, may here be introduced as
a further introduction to the subject under special consideration.
Sugar, as generated by the liver, can be traced to the right side of the
heart and to the lungs. Now what disposition is made of this saccharine
material in the pulmonary organs ? In the lungs, the sugar may be largely
destroyed and eliminated as carbonic acid and water, an evolution of heat
attending the metamorphosis, and a partial explanation afforded respecting
the maintenance of animal heat. An analogous process of vital chemistry
is observed in young and growing plants, by which sugar is made subser-
vient to the production of a suitable degree of temperature. The process,
however, is not an identical one. Part of the sugar in vegetables, under
the influences of bio-chemical transformations, is converted into permanent
tissue ; while another part is broken into its elements to form varied organic
associations, and during these combinations and recombinations an evolu-
tion of heat occurs ; thus affording a necessary and normal temperature to
cotyledons, radicles, and plumules of the tiny embryo, and indeed to grow-
ing plants of maturer growth. Phyto-chemical processes are with diffi-
culty observed, but under master minds have been interpreted. If we
turn either to the most infinitesimal or to the most gigantic vegetable
forms, we find them possessed with the power of maintaining a tempera-
ture adapted to the necessities of each ; and in them starch, sugar, and oil
352
Smith, Glycogenesis and Bright's Disease.
[April
play important roles as heat-producing factors. In the animal kingdom,
both the insignificant and the potential forms of life are endowed with the
power of maintaining a certain degree of temperature. Diverse as are the
vegetable and animal creations, kindred proximate principles are operative
in both, in the production of kindred results, though the processes of vital
chemistry may not be alike in the two realms of nature.
Respecting the disposition of hepatic sugar in the economy, while a
part of the saccharine material may be destroyed in the lungs and its ele-
ments eliminated, another part may be converted in the pulmonary organs
into some other principle or principles which the physiologists have not
recognized, and which, passing into the circulation, may either be chemi-
cally disposed of and eliminated, or be converted into tissues composed of
carbon, hydrogen, and oxygen. As a result of these and of other chemi-
cal processes, warmth is generated — a warmth so tempered by the divine
will, that a glow is maintained, genial and adapted to the different classes
and species of animals.
There are good reasons for believing that hepatic glycogenesis is in-
creased at times, both under normal and abnormal conditions. It appears
to me it can account for obesity. In those individuals inclined to the
accumulation of adipose tissue, the liver doubtless generates more sugar
than ordinary, and it is disposed of in the economy by a conversion into
fat. As corroborative of this, it may be stated that we not unfrequently
notice a temporary glycosuria in stout persons. This variety of diabetes
is not ordinarily fatal, and I account for the occurrence of the phenomenon
in this manner : more sugar is occasionally formed than can be utilized in
the system, and the surplus passes away in the renal secretion.
A normal augmented hepatic glycogenesis occurs, I think, during lacta-
tion ; the irritation of the mammary glands, etc., at the close of gestation
excites, by a nervous influence, increased sugar formation in the liver, the
blood of the general circulation becomes charged with it, this sugar is
separated from the blood by the mammary glands, and appears somewhat,
modified as lactose in the milk. In proof of this, it is known that milk is
richer in sugar early in lactation than at later periods ; and, again, nursing
women and milch cows have been observed to have a temporary melituria.
These phenomena, relating to the quality of milk and to glycosuria in
young mothers, which had been observed as clinical facts, had not, so far
as I was aware, been explained, and I have, on a former occasion, ac-
counted for them in this manner : mammary irritation early in lactation
is more potent than at later seasons, and better calculated to excite reflex
nervous influences ; and, again, more sugar is generated than is required
for the milk, and hence the appearance of the extra supply as an excretion
in the urine. Patients suffering with confirmed diabetes have been ob-
served to eliminate sugar in various secretions, as in the saliva and per-
spiration, as well as in pus.
1878.]
Smith, Glycogenesis and Bright's Disease.
353
It is a natural supposition, as a converse to the above, that sugar forma-
tion may be either arrested or diminished, and that symptoms indicative of
such condition should be as conspicuous as are those which are indicative
of an extraordinary quantity. Nature ordinarily may be so conservative
as to diminish or increase the production of sugar to meet the demands of
the system during the varying seasons of the year. In our latitude dia-
betes is a malady of rare occurrence ; in certain warm regions it is a dis-
order so frequently met with that scarcely a family escapes its appearance.
We recognize diverse causes as giving rise to the symptom of glycosuria.
In tropical countries we are aware of the great prevalence of hepatic dis-
orders, as provoked by a variety of circumstances, and it is probable that
the hepatic sugar, not being all required to maintain animal temperature,
is excreted in the renal secretion.
Among the patients constantly coming under our observation in this
climate, cases are often observed in which the patients are lean and dys-
peptic, and who suffer sensations of chilliness and have little endurance of
cold. These phenomena are particularly noticeable among those suffering
from functional and organic diseases of the liver ; there is probably, in
other words, a concomitant derangement of both the glycogenic and biliary
functions. Sugar is not degenerated in quantities sufficient either to
maintain animal heat or to be converted into fat. It is occasionally ob-
served that lean persons have a normal temperature, and can withstand
inclement surroundings. In such cases it is presumable that the saccha-
rine material is utilized in the economy in the production of heat, and not
in the production of adipose tissue. It sometimes happens that, when the
production of sugar is excessive, as in melituria, the temperature of the
patient is below the normal standard, the sugar being only partially
turned to a profitable account, the great mass of it being eliminated.
The fact is well recognized that certain nervous conditions favour an
abnormal increase in glycogenesis ; it would seem to be likewise true that
other nervous conditions occur which arrest or diminish sugar formation.
As it would be beyond the limits of this paper to discuss at length these
and other etiological points relating to these interesting phenomena, it
must suffice to confine our attention to a single sequel of a diminished
hepatic saccharine production. I shall have to omit a consideration of
numerous noteworthy points relating to the question how far derange-
ments of the glycogenic function directly or indirectly either cause or
modify various acute or chronic diseases. Variations of the function
modify vital processes, and induce both trivial and grave morbid sequelce.
If, as we have before seen, certain climatic causes can induce in the
kidneys organic disease, and if diminished sugar supply can induce a
diminished animal temperature, it seems a legitimate conclusion that persons
suffering under such saccharine impoverishment, and living in certain lati-
tudes, are peculiarly liable to renal disease. The function may be so dimin-
354 Smith, Glycogenosis and Bright's Disease. [April
ished that, without climatic causes, the system may be lowered in vitality,
rendering the kidneys peculiarly liable to chronic congestion and organic
lesion. A new factor of disease is thus found to be operative, and this
factor, simultaneously operative with other morbid factors, induces diverse,
complex, and widely diffused lesions. The more closely we study the re-
lationships of organs and functions, the more readily can Ave understand
their mutual dependencies, and the more clearly can we perceive how de-
rangements in one or more can induce derangements in others.
The conclusions to be drawn from the foregoing pages may be epitom-
ized as follows : —
First. Among the causes giving rise to one form of the disorder known
as Brigbt's disease, climate is recognized as a potential one — climatic in-
fluences being chiefly operative in such sections of the earth where the
vicissitudes of the weather are sharp and abrupt, especially as occurring in
localities of the temperate zone.
Second. One of the uses of the glycogenic function of the liver is to
maintain animal temperature. The function in question may be deranged
in various ways. Sugar may not be formed at all, or may be formed in
unduly large quantities, or may be generated so sparsely as to be insuf-
ficient to subserve the wants of the economy. In a case where the sugar
is suppressed, or is prepared in very moderate quantities, animal tempera-
ture is diminished, and the person suffers in a manner similar to that of one
exposed to harsh atmospherical conditions, and is liable to chronic conges-
tion and organic lesion of the kidneys; and if such an individual is a resi-
dent of a region in which the mean annual temperature is about 50° F.,
he is peculiarly prone to injury of the renal textures.
Third. Lessons in the prophylaxis of Bright's disease and the treat-
ment of the disorder are derived from the above considerations. As
means of prevention, care must be bestowed upon the nervous system, re-
sort must be had to dietetic measures, extreme attention being paid towards
promoting the healthy performance of the various functions, while the
artificial temperature of apartments and personal protection by clothing
when exposed to inclement vicissitudes are important measures of de-
fence.
Patients already suffering under chronic Bright's disease are by no
means irremediable, unless their cases are very seriously complicated. A
large proportion of such cases leave our hospitals relieved, and with the
prospect of future usefulness, if strict attention is paid to the salutary rules
of treatment which can be enjoined. It has fallen to my lot to see in
hospital, consultation, and private practice no inconsiderable amount of
renal disease — especially of Bright's disease. It has been to me a matter
of surprise how much can be accomplished by careful treatment in the re-
lief of such patients. When such invalids have been relieved of the more
urgent symptoms which confine them either to the bed, or to the room, or
1878.]
Smith, Glycogenesis and Briglit's Disease.
355
to the house, very much can be done by hygienic means to promote resto-
ration to comparative health, even though there is an assurance that the
kidneys have undergone organic changes and can never be reinstated to
an absolutely normal condition.
In promoting recuperation, special care is taken to relieve the kidneys
of all unnecessary work. The diet is particularly regulated, both, as re-
spects quality and quantity, so that only the essential requirements of food,
suited to each case, shall be ingested. In health the kidneys are con-
stantly overtasked in their duties by reason of the inconsiderate use as well
of solid aliments as of beverages. I have come to regard a rigid dietetic
regimen as being as essential to the restoration of patients suffering with
granular degeneration of the kidneys, etc., as the restricted diet in the man-
agement of diabetes, although of course the modifications and restrictions
are not the same in the two disorders. No less attention is paid to the
functions of the skin, and daily and general lavements and frictions are
insisted upon in order to promote increased cutaneous exhalation and
largely relieve the kidneys of duties ordinarily devolving upon them.
The temperature of apartments is made a matter of special regulation,
and clothing suited to in-door and out-door life is prescribed. While
under such hygienic measures, patients are further enjoined to take small
doses of corrosive sublimate, under which treatment amelioration is gene-
rally manifest. Without any change of climate, patients may thus be
placed under conditions rendering life not only comfortable, but also fitted
to perform the ordinary duties incident to it.
It occasionally happens, however, that harsh and wintry surroundings
are incompatible with such a degree of recuperation, and in advising the
removal of a patient to a genial clime, we have to consider, in the words
of Milton —
" By what means to shun
The inclement seasons, rain, ice, hail, and snow,
Which now the sky, with various face, begins
To show us, . . . while the winds
Blow moist and keen, shattering the graceful locks
Of these fair spreading trees ; which bid us seek
Some better shroud, some better warmth."
Postscript — On the completion of the above paper, and when about
mailing the manuscript for publication, an interesting and able article has
fallen under my notice in the American Journal of Science and Art, Feb.
1878, by Dr. Joseph Le Conte, denominated " Some Thoughts on the Gly-
cogenic Function of the Liver and its Relation to Vital Force and Vital
Heat." It has been my aim to give the foregoing article a practical bear-
ing ; the length of the paper has forbidden the presentation of the various
theories in regard to the precise manner by which sugar is formed as de-
rived from the liver. Several questions relating to this subject are still
sub judice, but physiologists agree that saccharine blood ordinarily flows
356
Fox, On the So-called Pigmentary Syphilide.
[April
from the liver, and without discussing mooted points regarding its source.
I have endeavoured to show how derangements of such a flow can unfa-
vourably affect the animal economy.
Dr. Le Conte, without alluding to the subject considered in this paper,
has alluded to a connection between the hepatic and renal functions. He
says :—
" We have seen that albuminoids, whether food or waste tissues, are probably
split in the liver into glycogen and some nitrogenous residuum. The glycogen is
changed into sugar, and then by oxidation into C02 and H20, and eliminated by
the lungs. The nitrogenous residuum, if it is not at first urea, is at least easily
changed into urea and eliminated by the kidneys. We see then the close rela-
tion between the functions of the liver and kidneys."
Article IV.
On the So-called Pigmentary Syphilide.1 By Geo. Henry Fox,
M.D., of New York.
There is a peculiar vitiliginous condition of the skin which in a more
or less marked form is occasionally met with in connection with early
syphilis. It is observed more frequently in females than in males, occurs
usually upon the sides of the neck, and constitutes the so-called pigmentary
syphilide. The description of the affection found in text-books, like the
description of other rare affections of the skin, is frequently based upon
reading rather than upon clinical study. As a consequence, the mistake
originally made, of regarding the abnormal pigmentation as a direct mani-
festation of syphilis, together with a few trifling misstatements, has obtained
a foothold in syphilographic literature, and we now find the affection bear-
ing a name which it does not merit and assuming an importance which it
does not possess.
A glance at the literature of the subject shows that the affection was
first described by Hardy, and later by Pillon, Tanturri, Bazin, Fournier,
Drysdale, and others. ITebra mentions the occurrence of loss of pigment
on the site of syphilitic papules and other cellular infiltrations, but makes no
special reference to the affection in question. Tilbury Fox describes the
maculse or stains which follow syphilitic lesions, but does not speak of any
circumscribed loss of pigment. Neither Zeissl nor Bumstead refers to the
affection. Van Buren and Keyes give a brief description, and remark
that " this eruption is sometimes, possibly always, simply a pigmentation
left behind by a roseola." Duhring dignifies the affection with the title
" Syphiloderma pigmentosum," and states that he has never met with a
case. Before giving my views as to the nature of the affection, let me
1 Head before the New York Dermatological Society, Jan. 8, 1878.
1878.]
Fox, On the So-called Pigmentary Syphilide.
357
attempt its description. This I shall base upon a careful study of what
has been written, and a close observation of cases which have occurred in
my practice.
The affection consists essentially in an abnormal distribution of pigment,
and is usually confined to a limited portion of skin. There occur both
light and dark patches. The light patches are circular or oval in form,
vary from a dime to a quarter dollar in size, and are scattered irregularly
over the affected surface. In some cases they would be scarcely notice-
able save by contrast with a hyperpigmented interspace or background.
The dark patches constituting this background are irregular in form, and
run together at their edges in such a manner as to encircle the pallid disks
above mentioned. These dark patches, which usually exceed in area the
inclosed islands of lighter hue, have been described as being of a gray or
coffee colour, and writers frequently give the differential diagnosis between
the pigmentary syphilide and freckles, chloasma and tinea versicolor. This
comparison is liable to mislead the reader, since the affection is rarely as
striking in appearance as either of the affections named. Sometimes it can
only be noted by allowing the light to strike the skin at a certain angle.
The hue of the dark patches is best described as a dirty-skin colour, and
when occurring in its most frequent site, upon the neck, the physician and
even the patient is apt at first to regard the affection as simply due to a
lack of soap and water. The favourite location, as just mentioned, is the
neck, the lateral portions of which are involved in the great majority of
cases. Fournier's statistics give it there in 29 out of 30 cases. I have seen
one case in which the affection was well mar"ked upon the trunk and upper
extremities, while others have recorded its occurrence upon the face and on
the lower extremities.
According to Fournier, the pigmentary syphilide occurs almost exclu-
sively in the female. In fact, he admits that he has never met with it in
the male. Doubtless this results from his having made his studies of
syphilis largely among females. It is certain that for a somewhat similar
reason the cases which I have met with have been males.
At a recent meeting of the Medical Society of London, Dr. C. R. Drys-
dale read a paper on the "pigmentary syphilide in the female." He
reported the occurrence of the affection (upon the neck) in 14 out of 41
cases of secondary syphilis. Here the 14 cases were necessarily females,
as the 41 were of that sex. Hardy speaks of the occurrence of the pig-
mentary syphilide in males as being exceptional, and only to be noted in
individuals of a lymphatic temperament and fair skin. Others, too, have
only observed the affection in those males who possess a feminine skin,
"white, delicate, and transparent." It is evident that upon the neck of
beardless youth the pigmentation will naturally be more striking in appear-
ance, and hence more frequently observed than upon the hairy neck of older
men, and yet it may not be of more frequent occurrence. As regards its
358
Fox, On the So-called Pigmentary Syphilide.
[April
predilection for those males only who possess a fair complexion, I must
differ with the writers, and in this connection I would refer to a photo-
graph of a dark-skinned Italian upon whose body I found the affection to
be exceptionally well marked.1 The fact that the pigmentation is usually
observed in the female is not alone a proof that it usually occurs in that
sex, as is commonly stated to be the case. It should be borne in mind that
the pigmentation is seldom marked in appearance, and is unaccompanied
by either elevation of the skin, pain, pruritus, or desquamation. Consisting
therefore in nothing more than a very trifling disfiguration, it is evident
that a woman would be far more likely to notice and call attention to the
affection than would a man. And when we remember that even upon the
neck of a woman the pigmentation is often seen with difficulty, we must
admit that the same condition might be present upon the rough, weather-
beaten neck of her husband and yet be almost invisible. I will not deny
that the affection occurs more frequently in the female sex, although I
imagine that, if the pigmentation were sought for in all cases of syphilis,
there would not be found so great a disproportion of cases as is reputed to
exist.
The period at which this pigmentation is apt to develop corresponds
with Avhat is commonly known as the secondary stage of syphilis. It may
appear any time between the third and sixth month, and possibly later. It
is usually persistent, and may be noted long after the ordinary cutaneous
lesions of syphilis have disappeared. In the patient to whose photograph I
have referred, the disease had been contracted two years before. The fact
that this abnormal pigmentation of the skin develops about the time when
early cutaneous lesions have disappeared has an important bearing on the
question of its nature, and supports the view that it is not a direct manifes-
tation of syphilis, like the ordinary syphilodermata, but a non-specific affec-
tion of the skin occurring on the site of and as a sequel to a syphilitic
eruption.
It has been stated that the essence of the affection is an abnormal pig-
mentation of the skin. Light macules are seen upon a dark background.
Now, the question arises, Is there a loss of pigment in the lighter patches,
or are these simply patches of normal skin which appear light through
contrast with the surrounding hyperpigmentation ? Contradictory state-
ments are found in the literature touching upon this point. Hardy, in
his earliest accounts of the pigmem'ary syphilide, claimed that it was
characterized solely by an augmentation of pigment ; but later, he writes,
" these white spots, which might be taken for portions of normal skin,
appearing light by contrast with the surrounding discoloration, are true
macules, caused by a diminution in the amount or colour of the pigment."
In opposition to this, Fournier claims that the light patches are normal as
1 Photographic Illustrations of Skin Diseases, No. 68.
1878.]
Fox, On the So-called Pigmentary Syphilide.
359
to their hue, though appearing white by contrast, and remarks that "some
have been deceived by this appearance, and have claimed the existence of
a twofold pathological condition, viz., an increased pigmentation of certain
portions of skin, and a decreased* pigmentation of others." Now, have
these observers been deceived, or is M. Founder in error? A solution of
the question is to be attained by observation rather than by argument.
For my part, I am thoroughly convinced that in the majority, if not in all
cases, the circular or oval patches are abnormally white. The deviation
from the normal hue of the skin in the light macules may frequently be
too slight to justify a positive opinion as to any actual change in the pig-
mentation of the part, and there is no doubt that the dark background
tends to make the whiteness to a certain extent illusory. But in some
cases- the diminution of pigment is too manifest to admit of any doubt.
For instance, in the case photographed the light macules constituted, at
first glance, the only apparent lesion. They were unmistakably lighter
than any other portion of the patient's body, and as the hyperpigmentation
in the vicinity, instead of being the prominent feature of the affection, was
so slight as to be hardly noticeable, the illusory effect of contrast was
reduced to a minimum. If it be conceded, then, that in many, if not in
all, cases there exists a diminution, as well as an increase, of pigment, how
does the affection differ from vitiligo? " Vitiligo is an acquired disease,
consisting of one or more sharply-defined, round, oval, or irregularly-shaped,
variously-sized and distributed, smooth, whitish spots, whose borders show
an increase in the normal amount of pigmentation." (Duhring.) A brief
consideration of this definition will suffice, I think, to prove the identity
of the so-called pigmentary syphilide. It should be remarked here that
Hebra restricts the term vitiligo to achromatous spots of idiopathic origin,
which tend to enlarge and never regain their normal hue, while the achro-
matous spots, resulting from pressure and other local causes, he classes as
a separate form of acquired leucoderma. This distinction, however, is not
made by writers generally, and appears to me to be of doubtful value.
There would be as much or even more reason for restricting a term like
erysipelas to its idiopathic form.
The question which next arises is the following: Is this vitiligo of
syphilitic subjects a direct cutaneous manifestation of syphilis, like the
ordinary papular and pustular eruptions, or is it a non-specific local affec-
tion, appearing as a sequel rather than as a symptom of the systemic dis-
ease? The latter is my decided conviction. That the affection is of diag-
nostic importance as an indication of syphilis cannot be denied, and we
must admit its syphilitic origin, but it by no means follows that the affec-
tion partakes of a syphilitic nature. It is wholly uninfluenced by mercury
and other antisyphilitics, and often persists long after the ordinary mani-
festations of syphilis have disappeared. These facts have been remarked
upon as singular features by writers who regard the affection as a true
3G0
Fox, On the So-called Pigmentary Syphilide.
[April
syphilide. For my part, I do not consider them as at all strange. Be-
lieving the affection to be a vitiligo, syphilitic merely in its origin, I would
as soon expect mercury to produce an effect upon a syphilitic cicatrix, and
as far as its immediate dependence upon syphilis is concerned, it seems to
me that we have no more ground for speaking of a pigmentary syphilide
than we have to speak of a cicatricial syphilide. Both discoloration and
cicatrix are independent of, although the result of, syphilis. The one dis-
appears in time, the other is indelible.
I wish to show now that in the affection under consideration, the loss
of pigment in the whitish macules follows antecedent hyperpigmentation.
Such a change in portions of skin from an abnormally dark to an abnor-
mally light hue, would be merely an instance of that transformation which
frequently takes place, e.g., in the crescent edge of a patch of ordinary
vitiligo. Increased pigmentation following syphilitic lesions is a matter
of every-day observation. On the other hand, a diminished pigmentation
following such an increase has been noted by Taylor and Atkinson as
taking place in syphilitic papules upon the negro. I believe that a similar
pathological process obtains in case of vitiligo occurring in syphilitic sub-
jects, for I am certain that in all cases the pale circular patches occupy
the site of pre-existing lesions. The fact that the vitiligo usually develops
shortly after the disappearance of the early eruptions supports the belief,
and a more decided confirmation I find in my notes of the following case : —
Mr. J. S., a young man of lymphatic temperament, came to me with a
chancre in July, 1877. A macular syphilide appeared in August. In
September there was a copious eruption over the body, consisting of both
miliary and lenticular papules, which eruption, according to my notes,
was unusually marked upon the face and neck. This faded gradually un-
der mercurial treatment. In November, or about three months after the
outbreak of cutaneous syphilis, and at a time when the eruption had nearly
or quite disappeared, a vitiligo was observed upon the neck. The skin of
this region presented the characteristic dirty appearance. Upon the sides
of the neck small, circular, whitish macules were seen, varying in size
from a pea to a cent, and irregularly distributed over the surface after the
manner of an ordinary macular syphilide. The larger of these macules
exhibited a small dark central spot, like a very faint bull's-eye. The ab-
normal condition of the skin was not at all striking in appearance, and the
pallid macules were far less noticeable than the dirty hue of the surround-
ing skin.
Mercurial treatment has been continued in this case, and when the pa-
tient was last seen the syphilitic eruption had entirely disappeared, while
the discoloration of the neck remained. I desire to call attention to the
fact that in this case the syphilitic eruption was noted as being unusually
copious upon the neck, and that the vitiliginous macules which followed
the congestive maculo-papules of syphilis not only appeared in the cervical
region, but exhibited a distribution similar to that of the preceding erup-
tion. I could not state from actual measurements that the vitiliginous
macules occupied the exact site of antecedent syphilitic lesions. It is quite
probable, however, that they did ; and if I am not mistaken respecting
the nature of the dark central spots, it is absolutely certain that they did.
1878.]
Fox, On the So-called Pigmentary Syphilide.
301
The dark spots in this case were, without doubt, a relic of the pigmenta-
tion following the syphilitic papules ; and it is evident, therefore, that the
number and location of the vitiliginous macules was determined by the
number and location of the preceding syphilitic lesions. These dark
points, noted at the centre of the 'circular, whitish macules, constitute a
feature of which no mention has heretofore been made by writers on the
pigmentary syphilide. They are undoubtedly of rare occurrence, and if
present at all, are only to be observed in the incipient stage of the affec-
tion.
The development of this vitiligo of syphilitic origin would seem, then,
to take place in the following manner: The maculo-papules of early sec-
ondary syphilis, whether upon the neck or elsewhere, induce primarily a
hyperpigmentation. At the periphery of these dark stains, an atrophy or
degeneration of the pigment cells ensues. The dark stains dwindle to
dark points, which speedily disappear, and circular or oval whitish macules
of a larger diameter than that of the original lesions occupy their site.
The portions of skin adjacent to these whitish macules become, as in ordi-
nary vitiligo, the seat of a complementary pigmentation, and present a
discoloured appearance, which usually forms the most prominent feature
of the affection.
And now, to sum up in brief the salient points of the foregoing, allow
me to present the following statements : —
I. The pigmentary syphilide as described by Hardy and others is not a
direct manifestation of syphilitic disease.
II. It is a non-specific vitiligo, which, though syphilitic in its origin,
cannot be properly classed among syphilitic lesions.
III. It is most frequently observed upon the neck, but may be well
marked upon various other portions of the body.
IY. It is usually more apparent upon females, but is by no means pe-
culiar to this sex. Nor is it always associated with a fair complexion.
Y. The whitish macules, which constitute the most important feature
of the affection, are not merely white by contrast with a hyperpigmented
background, but in consequence of a loss of pigment.
YI. These macules occur upon the site of pre-existing syphilitic lesions,
remains of which may sometimes be observed as dark central points.
VII. The hyperpigmentation surrounding the macules is of secondary
importance, although in the majority of cases it constitutes the most
striking feature of the affection.
208 West Thirty-fourth St., New York.
No. CL April 1878. 24
3G2
Burnett, Visual Acuteness in Ametropia.
[April
Article V.
On the Visual Acuteness in Ametropia of High Degrees. By
Swan M. Burnett, M.D., Lecturer on Ophthalmology, Medical Depart-
ment of Georgetown University, Washington, D. C.
Conventionally the acuteness of vision (V) is marked by the small-
est visual angle under which certain objects (test-letters) are distinctly
seen. The formula expressive of this is V=^, wherein d expresses the
distance at which the object is seen, and D the distance at which it should
be seen under an angle of five minutes ; the separate lines composing the
letter appearing under an angle of one minute, which is accepted as being
the (mean) smallest angle under which two objects can be clearly differen-
tiated from each other. For instance, No. 5 of Snellen's test-types ap-
pears under an angle of five minutes at a distance of five metres ; No. 1 at
a distance of one metre, etc., and when they are seen with distinctness at
their respective distances V is said to = § or }.
In this determination, no account is taken of the distance of the object
or the size of the retinal image, except in so far as they are related to the
visual angle ; and while it is a fact that the visual acuteness depends di-
rectly upon the size of the retinal image, the visual angle in cases of
emmetropia is a measure of the size of this image, and thus indirectly of the
visual acuteness. For such cases, therefore, we are justified in taking
measurements of the acuteness of vision, by test-types constructed on this
basis, as accurate.
But the large proportion of cases in which we test and record the
visual acuteness, is not of emmetropia. In these cases there is an error
in the refraction of the eye, or, to speak more correctly, there is a devia-
tion from the normal relation which should exist between the length of
the eye and its refracting power.
It is a well-known fact that under the same visual angle, the size of the
retinal image is modified by the position of the second nodal point, in re-
spect to the retina — the further removed it is from the retina, the larger
the image, and the closer it is, the smaller. With but few exceptions, all
cases of emmetropia (excluding astigmatism) are due to an anomalous posi-
tion of the second nodal point in regard to the retina. In myopia, on
account of the elongation of the globe, the retina is removed from it ; in
hypermetropia, where the eye is abnormally short, the retina is approxi-
mated to it. In such cases, therefore, it is evident, since the acuteness of
V is directly dependent upon the size of the retinal image, that a common
visual angle cannot be accepted as a measure of visual acuteness.
1 Snellen. Optotypi ad visum determinandum, 1875.
1878.]
Burnett, Visual Acuteness in Ametropia.
36o
In noting the influence which the two forms of ametropia exert on visual
acuteness, Ave shall first consider its action on distant vision ; and pri-
marily, the case of myopia, and in that form where the globe is elongated
and the distance between the second nodal point and the retina widened.
In order for the myopic eye to have distinct distant vision, it must be
armed with a concave glass of such a strength as to give parallel rays a
direction as if they came from the punctum remotum of that eye.
In giving a distinct image of distant objects, however, the auxiliary
lens alters the position of the second nodal point ; it is brought closer to
the retina. The exact amount of this displacement has been calculated
by Knapp,1 Landolt,2 Mauthner,3 Woinow,4 and others. These calcula-
tions show that when the neutralizing auxiliary lens is worn at the usual
distance, half an inch, from the cornea — which is about the anterior
focal point of the emmetropic eye — the second nodal point is made to
occupy a distance from the retina equal to that found in the emmetropic
eye, i. e., fifteen millimetres (taking as the basis of calculation the reduced
or diagrammatic eye of Listing and Donders).5 The result is that the
retinal image of a distant object in the myopic eye armed with a neutral-
izing glass placed in its anterior focal point, is of the same magnitude as
that of an emmetropic eye (Landolt, I. c.) ; because, not only is the dis-
tance from the second nodal point to the retina the same, but as Knapp
(/. c.) has shown, the correcting glass exerts no influence whatever upon
the visual angle. The position of the first nodal point is not affected by
the correcting lens, and so long as it is unchanged, the visual angle must
remain the same ; it is only when both nodal points are made to advance
or recede together, that the visual angle is modified.
If, then, the retinal image is the same in the corrected myopic eye as in
the emmetropic eye, the visual acuteness ought to be the same. And,
indeed, this would be the case, if there were no change in the retina ac-
companying the alteration in the form of the myopic eye. Knapp (7. c.)
contends, however, that there is an alteration in the position of the per-
cipient retinal elements, and of such a character that the elements are sepa-
rated from each other, and the same number made to occupy a larger
extent of space than they would in the emmetropic eye. He assumes that
the number of retinal elements is the same in all eyes, and that they are
1 Arcliiv for Oph. and Otol., vol. i., 2, p. 377, et seq.
" Handbuch f. gesamt. Augenheilk. von Gi afe u. Samisch, B. iii. p. 10, et seq. Le Gros-
sessement des images ophthalmoscopiques, Paris, 1874.
3 Vorlesungen iiber die Optischen Fehlen des Auges, pp. 149-176, 1873.
4 Archiv f. Oph. xv. 2, p. 144, and xviii. 1, p. 349.
5 The discrepancy in the figures obtained by different observers for each lens, is to
be accounted for, in part, by the difference in value of the same number of lens, as ex-
pressed in millimetres, used by each. One great advantage from the introduction of
the metrical system is, that these values being the same, the results of all calculations
must exactly correspond.
334
Burnett, Visual Acuteness in Ametropia.
[April
scattered over a larger space in M, and are more compacted in H. As a
consequence of this, a retinal image of the same size would cover more
retinal elements in H and fewer in M, than in the emmetropic eye. and
therefore the smallest perceptible image in M must be larger, and in II
smaller, than in E. He has constructed a table showing what the modifi-
cation of V is for each correcting lens, as representing the amount of sepa-
ration of the percipient elements in M, and of their consolidation in II.
taking E and a visual angle of five minutes as a standard. He takes as
an expression of this the distance at which, after correction, the ametrope
should read No. 20 (old*style) of Snellen. Of course in M it is shorter
and in H it is farther than in E.
Now, with our present knowledge, physiological and pathological, of the
retina, it would be impossible to assert, with positiveness, that there is
such a change in the position of the retinal elements in the two forms of
ametropia.
On this point Donders,* in speaking of his own dissections of the retina
in such cases, says : —
" But what here has particular bearing, how far morbid changes occurred in
these percipient elements, how far they were more separated than in the normal
eye, how the bulbs in the yellow spot, and particularly in the fovea centralis, are
circumstanced in high degrees of atrophy ; on these points I cannot speak with
certainty." (p. 378.)
However, in speaking of the same subject further on, he says : —
"It is easy to see, although it has not been proved by accurate microscopic
investigation, that under such extension the outermost layer, which consists of
radiatingly-placcd , very small bulbs, as Ave have seen, must suffer; that these
bulbs, at least, must be separated, irregularly distributed, and made oblique, and
that they must easily be actually destroyed. . . . Where there is vital meta-
morphosis of matter, change of form much more readily takes place under the
molecular change, without disturbance, than in solid fibrous parts, and in this
respect the retina has a great advantage over the sclerotic." (p. 382.)
And again :
" But on the other hand, the surface of the retina is also larger, and therefore
in a given plane comprises fewer percipient elements." (p. 390.)
It would appear, from the above, that Donders has accepted the sepa-
ration of the retinal elements in M, not from anatomical demonstration,
but because it best explained the diminution of Y as found in such cases.
In his tables Knapp shows that in M of less than 3.5 D (j1^) when
neutralized the decrease of Y is not practically of any moment, but above
that is sufficient to be taken into consideration. When the M amounts to
15 D Y is so much diminished in correction by glasses, that Snellen
No. XX. (old style) can only be made out at 14^ feet.
We find a totally different state of affairs in H dependent upon a short-
ening of the globular axis. As there is no such thing as negative
accommodation, that is to say, the eye not having the power to lessen its
refractive condition, the myopic eye cannot, unaided by extraneous lenses,
Anom. of Refrac. and Accom.
1878.]
Burnett, Visual Acuteness in Ametropia.
305
have distinct vision at a distance. In H, on the other hand, where there
is a relative deficiency of refracting power, the eye can, by means of the
muscle of accommodation, increase its refraction, and obtain a distinct
image of distinct objects. What, then, would be the visual acuteness in
this case as compared with the emmetropic eye? As we have already seen,
the visual angle cannot any longer, in such a case, be taken as a measure ;
we must fall back on the size of retinal image. We have also further seen
that the size of the retinal image is regulated by the distance of the second
nodal point from the retina, and our task in this instance, as in the
other, is to find this relative position of the second nodal point. As the
power of refraction of this hypermetropic eye is the same as that of the
emmetropic eye, the optical constants are the same, and the position of
the second nodal point in relation to the cornea is unaltered; it is found,
therefore, five millimetres (in the diagrammatic eye) from the apex of the
cornea. But as the length of the eye is reduced, the distance from the
second nodal point to the retina is diminished i instead of being, as in the
emmetropic eye, fifteen millimetres, it is less, and, of course, the distance
is smaller in proportion as the eye is shorter. The effect of this must,
evidently, be to diminish the size of the image. We know, however, that
the hypermetropic eye, in a state of rest, does not unite parallel rays upon
the retina ; it is only when it puts forth an accommodative effort that this
can be accomplished. It remains, then, to determine if the act of accom-
modation can change the size of the retinal image by altering the position
of the second nodal point.
Mauthner (7. c.) lias made the calculations necessary to determine this
point, and has found that the act of accommodation exercises but an insig-
nificant influence on the position of the nodal points, the advance of these
points, in an accommodation of 9 D (^), amounting to only 0.4 to 0.5
millimetre, which is so small as to be entirely neglected so far as its influ-
ence on the size of the retinal image is concerned. The size of the retinal
image of a hypermetrope, who corrects his faulty refraction by means of
the accommodation, is, therefore, smaller than in the emmetropic eye.
It is quite otherwise, however, when the H is corrected by a lens placed
in the anterior focal point of the eye. The correcting auxiliary convex lens
causes the second nodal point to advance to such a position, that it shall be
at the same distance from the retina as in the emmetropic eye. As in M,
therefore, the size of the retinal image in H corrected by glasses at one-
half inch from the eye, is the same as in E.1
1 That there is an appreciable difference in the size of the retinal image in H, when
corrected by glasses, and by an increase in the curvature of the crystalline lens, has
been experimentally demonstrated by Landolt on his artificial eye, for a description of
which see " The Introduction of the Metrical System into Ophthalmology," Royal Lon-
don Ophthalmic Hospital Reports, May, 1876. When in Paris in 1876, 1 had the oppor-
tunity of experimenting with him on his eye, and the results obtained accorded very
closely with the calculations he had made.
3GG Burnett, Visual Acuteness in Ametropia. [April
The visual acuteness, therefore, would be the same if the image covered
the same number of retinal elements. But, according to Knapp and Bon-
ders, the number of percipient elements covered by this image is greater
than in a correspondingly large image in E, and hence the acuteness of V
is increased, and, of course, increased in proportion to the increase in the
strength of the glass used.
It is in these cases of H that we are in condition to compare the visual
acuteness with and without glasses, because, as we have said, the anomaly
in refraction can be corrected, either by the accommodation (at least, in
cases so high as 7 D (|)), and by the auxiliary lens. I think the experi-
ence of the profession will bear out the assertion that visual acuteness in
the higher forms is not so good when the H is overcome by the accommo-
dation as when corrected by a suitable lens. I think that in cases so high
as | (4.5 D), which a young person of fifteen years could easily overcome
by means of the accommodation, the visual acuteness for distance rises very
materially when neutralizing glasses are applied. This increase can, of
course, only come from an enlargement of the retinal image, brought about
by the lens, since its distinctness of outline is the same in both cases.
It is, however, in hypermetropic cases of high degree that we meet
with the instances of lowered visual acuteness which cannot be accounted
for by either regular or irregular astigmatism, and which it has been the
custom to refer to an arrest of development. The hypermetropic eve is
considered by all authorities, I believe, to be one that has been arrested
in its development, and thus failed to attain to the dimensions taken as
the normal standard ; and, in many instances, this arrest in development
has not been limited to the globular case itself, reducing it in its dimen-
sions and notably in its antero-posterior axis, but has extended to the
nervous apparatus, and either diminished the number of the percipient
elements or impaired their function. That the number of retinal ele-
ments is the same in the myopic eye as in the emmetropic is probable,
since they may both have been originally of the same size, but, I think,
clinical observation would hardly justify us in assuming so much for the
hypermetropic eye.
It has been shown that, for distant vision, myopes have lessened retinal
images, and consequently diminished visual acuteness, when their anomaly
is neutralized by glasses placed in the anterior focal point of the eye ; and
that hypermetropes, under the same conditions, have larger images and
better vision than when their hypermetropia is overcome by accommoda-
tion, and presumably better than in emmetropia.
It now remains to examine into the state of near vision in each case,
and note its relation to distant vision. And this is a point which, though
touched upon by some — especially Donders and Landolt — has not been
yet considered in detail to the extent it deserves. Unless it be taken into
1878.] Burnett, Visual Acuteness in Ametropia. 367
consideration, we are liable to fall into errors, and refer the diminished
vision Ave may find in any case to a wrong cause.
If we have a case of myopia, for example, where, with No. 9, No. 18
of Snellen is read at six metres, we should not be justified in considering
vision as only one-third of the normal (T6s), for upon the examination of
near vision we might find it quite up to the standard.
There are two causes for the superiority of near over distant vision in M —
1st, the larger retinal image ; and 2d, the larger visual angle, which it is
possible to obtain without a strain on the accommodation.
We have, indeed, recently examined a case where just these conditions
were present.
A girl of thirteen years could only read part of No. 18 at six metres
with No. 9 Q), combined with a cylindrical No. 1, axis horizontal. This
Avas the best distant vision a prolonged and close examination was able
to afford her. Yet without glasses she read Snellen 0.3 (J. 1) at ten
centimetres with ease.
That the retinal image in the near vision of myopes is larger than that
of distant vision through glasses, or even in the emmetropic eye, is readily
understood from what has been said about the position of the second nodal
point in the myopic eye. In the unarmed myopic eye, at or within its
punctum remotum, the second nodal point remains essentially in the same
position as that of the emmetropic eye. The distance from this point to
the retina, however, is greater than in the emmetropic eye. On account
of the increased length of the globe, as we have already shown, the re-
tinal image is correspondingly large. If, however, we accept the theory
of Donders and Knapp that, on account of the stretching of the retina, this
enlarged image covers only the same number of elements as in the em-
metropic eye, and if, in this stretching, there has been no damage done to
the elements which impairs their function, the near vision of myopes, with-
out glasses, should be as acute as that of the emmetropic eye. In all cases,
therefore, of myopia trom stretching of the globe, the visual acuteness at
a distance, after correction by glasses, should never be accepted as ex-
pressive of the best vision that eye is capable of. The myopic eye of this
description, as is well known, is liable to very grave pathological altera-
tions of an inflammatory character, and it is important that we know if
such processes have done serious damage to the percipient retinal elements.
If Ave find, on examination, that near vision approximates to the accepted
normal, then Ave may justly conclude that these elements are not seriously
affected.
Another reason why both near and distant A^ision should be noted is that
the difference between the two is liable to great Arariation. Thus a AA'oman
of thirty-five Avas able to read most of Snellen's XXX. (old style) at tAventAr
feet with — L (-18 D.), and J. 1 was read fluently at six centimetres. Such
good distant Arision is seldom met AATith in myopia of such a high degree,
368
Burnett, Visual Acuteness in Ametropia.
[April
though it still falls below the acuteuess which Knapp has calculated a myope
should have whose anomaly is corrected by a lens of two inches focal dis-
tance. According to him, this woman should have been able to read
Snellen's XX. at about fifteen feet (V = f), whereas she had only V = §.
Both in this case and the other just related, there was great thinning
of the choroid, and large crescents at the optic nerve entrance ; in the
latter case the atrophy completely surrounding it.
In hypermetropia, where the eye is shortened and the nodal points
have the same relative position to the cornea as in the emmetropic eye,
it is evident from what has been already said, that the retinal image in
near vision, though it be rendered distinct through the accommodation,
is smaller than in E. But, if it covers the same number of elements
as the larger image would do in E, V should be as acute, and when the
faulty refraction is corrected by a glass placed in its anterior focal point,
the image should be of the same size as that in E, and the visual acute-
ness greater. We are in great need of statistics on this point, but so
far as my individual experience goes, it would tend to refute this idea.
In H of high degree I have rarely found either distant or near vision
to come up to the normal, after correction. This is, I think, to be
accounted for, abstraction made of astigmatism, regular and irregular,
by the arrested development of the percipient elements. However well
the theory of Donders and Knapp may apply to cases of M, where we
can see for ourselves the stretching of the retina, its application to the
condition of H, where there is an evident arrest in the developmental
process, is attended with extreme difficulty, and is hardly, I think, sup-
ported by the facts in the case.
But H and M may come, not only from an alteration in the length of the
eyeball, but also from an alteration in its refraction, and a few words must
be devoted to these conditions. The essential results in these cases are
the same, though arrived at in a different manner.
We will take, first, a case of M from increase of refraction. Here
the eye is of normal length, and the position of the nodal points in
regard to the retina, though altered somewhat, is not more so than in
an eye which is made myopic through its accommodation ; and, as we
have seen, we are able to neglect this, practically. The image of a
distant object, therefore, formed on the retina by means of a correcting
auxiliary lens, must be smaller than in the emmetropic eye, since the
second nodal point is brought nearer to the retina; the acuteness of vision
for distance is therefore less, because the retinal elements being the same
as in the emmetropic eye, this smaller image covers a less number. In
near vision, on the other hand, the image being of approximately the same
size as that of the emmetropic eye during accommodation at the same dis-
tance, the visual acuteness must be the same.
In hypermetropia from a diminution of refractive power, the reverse
1878.] Burnett , Visual Acuteness in Ametropia. 369
obtains. Here, through correction by glasses, the second nodal point
is removed from the retina, and the size of the retinal image correspond-
ingly increased ; and as the retinal elements have the same compact-
ness as in the emmetropic eye. the visual acuteness should be greater.
The most prominent instance of this condition is. of course, aphakia ;
and we should here have the opportunity of verifying the calculations
made by Knapp and others, showing the increase above the normal
standard, of the visual acuteness, in corrected cases of aphakia! eyes.
When I say that an aphakial eye corrected by a -j- ^ (0. S.) should be able
to read Snellen's XX. at about 25 feet, according to these calculations, it
will be readily seen how extremely rare it is for those who have been
operated on for cataracts to have V = l. There are factors, however,
operating in this instance to lessen the visual acuteness, of which account
should be taken. Patients on whom extraction is made are generally old,
and there is always a greater or less loss of sensibility of the retina attend-
ing age ; and the cataractous eye is. from the very circumstance of its
having become cataractous. a diseased eve. So we should, in the majority
of instances, not look to obtain Y = 1.
To sum up. then, the facts, which the investigations to which Ave have
referred have brought out in respect to the acuteness of vision of ametro
pia of high degrees, we would say : —
1. That a common visual angle cannot, in such cases, be accepted as
the unit of measurement, since it no longer is an index of the size of the
retinal image.
2. That in M, distant vision through neutralizing glasses is less acute
than in the emmetropic eye. while in near vision, without glasses, it is the
same ; that in H, distant and near vision, where the anomaly is corrected
through the accommodation, are less acute than where it is corrected by
glasses, and that in the latter case they should be better than in E. if the
theory of an unvarying number of retinal elements in all human eyes be
accepted.
It seems, probable, however, that this theory does not hold good in a
large number of cases of H, and consequently Y. when corrected by
glasses, instead of being better, is only the same, if so good, as in E. We
are in want of accurate statistics on this point.
3. That it is important to note, particularly in the case of M. the visual
acuteness. both for near and for distant vision. TTe often rind greater
discrepancies between them than the theoretical calculations would allow
us to expect. We thus acquire some idea of the extent of damage done to
the percipient elements by the morbid processes at work at the fundus of
the eye, in those cases where the M is due to stretching of its coats.
It has seemed to us unnecessary to give any tables showing the amount
of increase and diminution of the visual acuteness caused by auxiliary
lenses in cases, respectively, of H and M, However accurate they may
370 Lefferts, Lupus of the Larynx. [April
be theoretically, in practice we find so many other factors in the case
that we cannot trust them as guides. It appears to us sufficient to know
that there is an influence exerted by them, and to give it due consid-
eration in connection with the other facts.
February 1, 1878.
Article VI.
Lupus of the Larynx, A Clinical Study. By George M. Lefferts,
M.D., Clinical Professor of Laryngoscopy and Diseases of the Throat, College
of Physicians and Surgeons, New York; Laryngoscopic Surgeon to St. Luke's
Hospital, etc.
Whether the rarity of recorded instances of lupus of the larynx de-
pends upon a paucity of investigation, whether the disease will oftener be
found if it be looked for, lupus of the cutaneous surface not being such a
very unusual affection, or whether the morbid process in truth really in-
volves the laryngeal parts but seldom, are questions, it seems to me, not
only of general interest, but likewise of diagnostic and therapeutic import-
ance, and ones that can only be decided by further observation and with
the aid of the laryngoscope. As the question stands to-day, we must re-
gard the laryngeal complication as a rarity. I have searched the litera-
ture of the subject with but meagre results. The majority of writers pass
it by without mention;1 a few refer to the investigations of others;2 while
in four instances3 alone is original observation, the result of personal
examination, to be found upon record. Turck*1 heads this list with four
cases, in which there was no doubt as to the correctness of the diagnosis,
and one in which he confesses himself as not being certain. Their histo-
ries, together with two drawings of the laryngoscopic picture, will be found
in his classical work, and, though the earliest, will still be found the best
contribution to our knowledge of the disease in question. Tobold5 fol-
lows with an incomplete account of two cases ; while more recently Ziems-
sen6 and Grossman7 have each added one case to the general fund. Ten
cases then, if I include my own, are upon record, and it may be of interest
to note that in all of them, with the exception of Ziemssen's, lupus of the
cutaneous surface, face, back, arms, etc., likewise existed.
1 Porter, Ryland, Voltolini, Ruhle, Columbat, Marcet, Navratil, Stork, Fauvel, Dur-
ham, Dufour, Baiimgartner, Mayer, Schrotter, Cohen, Gibb, Bruns.
2 Mackenzie, Mandl.
3 Turck, Tobold, Ziemssen, Grossmann.
4 Turck, Klinik der Krankheiten des Kehlkopfes, 1866, p. 425.
5 Tobold, Laryngoseopie und Kehlkopf Krankheiten, p. 307.
6 Ziemssen, Cyclopaedia, vol. vii. p. 854.
T Grossmann, Allg. Wiener Med. Zeitung, No. xx. 1877, p. 182.
1878.]
Lefferts, Lupus of the Larynx.
371
My personal experience in the diagnosis and treatment of affections of
the larynx, not an inextensive one, agrees with the facts developed by a
research into laryngoscopic records, and the one case which I have had an
opportunity of observing seems to. me, therefore, to assume, on account of
its very infrequency, a practical importance that renders it, as I have
said, of general interest, and makes it one that it is desirable to place upon
record. Its history is as follows : —
Mrs. M. J. M., set. 44, consulted me in October, 1877, at the request
of Dr. Bulkley, on account of a serious and progressive difficulty in deglu-
tition. For years she has been a victim of lupus, and the terrible disfig-
urement of her face, associated more lately with a distortion of the eyelids
and mouth, which interferes markedly with the proper performance of
their functions, together with the trouble above alluded to, has done
much to render her life a most miserable one. According to her state-
ment, the dysphagia was rapidly becoming excessive, and, though she
now suffered no pain, great difficulty was experienced in obtaining suffi-
cient nourishment, the deglutition of solids being nearly impossible of ac-
complishment, while fluids at times caused her great distress by passing
into the larynx, and causing violent and paroxysmal cough. No other
symptoms other than a sense of fulness and distressing obstruction in the
throat were complained of, and her voice is unimpaired. She dates the in-
ception of her throat affection one year since ; at which time the throat,
having been previously perfectly healthy, as she believes, certainly as far
as any rational symptoms go, commenced to give her pain at and after
each act of deglutition. The pain is described as being sharp and lanci-
nating, extending into the left ear, and being mainly confined to the right
side of the larynx. It continued with varying intensity up to two months
ago, when it ceased.
For a length of time the patient has been under the care of Dr. L.
Duncan Bulkley for treatment of the cutaneous manifestations of her dis-
ease ; and, recognizing the important bearing which they have upon the
correct and differential diagnosis of the laryngeal complication, I have
asked him to give me an expert description of them. He has kindly com-
plied as follows : —
" Mrs. M. first came under my care for her lupus December 14th, 1876,
when the following history was obtained : When thirteen years of age the
disease first appeared upon the left side of the nose in a tubercle resembling
in nature those now present on some portions of the eruption. During
the thirty-one years which have elapsed since that time the eruption has
progressively spread, although she has been under medical treatment for
the greater part of the time, and has followed each measure for a long-
period.
" The present condition of the eruption may be thus described : The
entire face is involved in the lupous process, from the border of the hairy
scalp above to the middle of the neck below, and from an inch behind one
ear, over to the same distance behind the other, with the exception of two
small patches of healthy skin, perhaps of a total of two square inches, at
the border of the hair, one above each eye. The whole of the surface is
of a dark red colour, shiny, with many very thin and very transparent
scales, attached at one edge, of greater and smaller size. There are at
present a few spots of superficial ulceration, as on the left cheek, at the
corners of the mouth, and at the meatus of the left ear.
372
Lefferts, Lupus of the Larynx.
[April
" Most of the surface has a pulpy feel, which is exhibited most strikingly
at the lobes of the ear, which are lost entirely in the extension of the dis-
ease, and are bound down to the sides of the cheeks ; the whole skin tissue
of the external ears is infiltrated, even deep into the meatus ; they are
immovable, and the sulcus behind them is lost. The end of the nose has
disappeared in the progress of the disease, mainly, she says, from the effect
of previous cauterizations ; the lips are largely infiltrated, so that the
mouth remains open most of the time, and the lips do not meet in con-
versation. Upon the cheeks the inroads of the disease have so replaced
healthy skin, and so much cicatricial tissue has formed, that very serious
ectropion exists in both eyes, causing her very much distress ; the upper
eyelids are also the seat of lupous deposit.
" While the mass of the eruption presents the almost uniform appearance
common to these cases, at the margins the separate elements of the disease
are clearly visible, both in the rather irregular borders, and in the isolated,
dark-red, pulpy, and slightly scaly tubercules of various sizes located
near by.
" There is also one more patch of typical lupus situated upon the back,
over the lower angle of the right scapula, of the size of the palm of a small
hand, and composed of a number of isolated and confluent, slightly scaly,
dark-red, and pulpy tubercles. There is no other cutaneous manifestation
of lupus save these mentioned."
Such, then, is the history of the patient, and careful questioning fails
to develop any further points of importance. Her antecedents and per-
sonal condition in respect to any possible evidences of tuberculosis,
syphilis, and carcinoma received the closest and most extended investiga-
tion. Syphilis she denies absolutely; and, being an intelligent and trust-
worthy woman, her statement is entitled to belief, confirmed as it is by an
entire absence of any physical manifestation of the disease. Pulmonary
tuberculosis is excluded by an examination of the chest, which is found to
be, in all respects, normal, while the diagnosis or suspicion of carcinoma
is entirely unsustained by either the hereditary or personal history and by
the absence of clinical corroborative evidence. The history, then, as far
as its facts in relation to her throat trouble go, is negative, or at least un-
decisive, for the rational symptoms give us no clue to the nature of the
pathological process. The laryngoscope now comes to our aid, and per-
haps alone. Certainly, when its revelations are taken into consideration
with the condition of the cutaneous surface, it solves the question, and
gives good reason, I think, for making the diagnosis that I have.
The pharynx, which is first inspected, presents an unusual, peculiar, and
perhaps characteristic appearance — one which, once seen, would be difficult
to forget or confound with other and common lesions. It resembles
nothing that I have before observed, except in some cases of advanced
phthisis, when some little similarity between the two conditions could per-
haps be traced. The first points which strike the eye are that its parts are
unsymmetrical, that the uvula is drawn to the right and downwards, the cor-
responding pillars of the fauces being much shortened, and that the general
hypertrophy or thickening of all the tissues, but notably of those upon the
right side, is remarkable; furthermore, that the right pillars of the fauces,
the free border of the palatine arch and the uvula, the latter increased to
more than two-thirds its original size, are thickly studded with fleshy
granulations, nodules, or tumefactions, which cause them to present a
most irregular outline. Here and there are scattered small white points,
1878.J
Lefferts, Lupus of tlie Larynx.
373
which, together with numerous places denuded of epithelium and small
superficial worm-eaten ulcerations, go to make up a marked and peculiar
picture, to which I am afraid my description does not do justice. The
posterior pharyngeal wall presents this same thickened and irregular ap-
pearance, and at a point corresponding to the free edge of the epiglottis,
which lies in front. Its surface is broken by three small but deep circular
ulcerations, with thickened edges. Above — that is, behind the velum — the
parts are not hypertrophied to the same degree as below, but present all
the evidences of an old catarrhal inflammation.
The base of the tongue, so thickened that it renders a laryngoscopic
examination somewhat difficult, is likewise dotted with these same fleshy
granulations, appearing much the same as the normal papilla?, which, in
this instance, are hypertrophied.
If we next turn to the larynx — the point, perhaps, of greatest interest
. — the laryngoscopic mirror will reflect the picture which is represented in
the drawing that I have made (Fig. 1). The essential pathological element,
which is indicated by the appearances, is hypertrophy of tissue — a hyper-
plasia and infiltration that has
changed to a marked degree the
normal configuration of the parts.
The second element is ulceration.
Taken together, they present a
type of disease that is best repre-
sented, were I to seek for a familiar
example for the sake of compari-
son, by tubercular laryngitis in
its later stages, but with certain
marked differences. To go more
into detail, I find the epiglottis so
hypertrophied that it not only
presses against the dorsum of the tongue, closing the vallecula3, but like-
wise overhangs the superior laryngeal aperture in such a manner that a
view of the interior of its cavity is much obstructed. It is hard, un-
yielding, immovable; its surface almost completely covered by minute
fleshy projections; while here and there are the same superficial worm-
eaten ulcerations, as are seen in the pharynx. This granular appearance
of the epiglottis — and I may compare it to the surface of an old hardened
and indolent ulcer, such as we see at other parts — is certainly unique, and
does not resemble in any degree the smooth surface presented by the
turban-shaped epiglottis of laryngeal phthisis ; still less does it simulate
the inflammatory tumefaction which may accompany a syphilitic ulcer of
the part. Is not this peculiar appearance, then, if further observations
prove its reliability, a differential diagnostic mark between the above
three affections — Lupus, Phthisis, and Syphilis?
The remaining portions of the upper larynx present alone evidences
of simple hypertrophy or plastic infiltration of its tissues. The aryteno-
epiglottidean folds — the membrane covering the arytenoid cartilages, and
the parts embraced in the posterior commissure of the larynx, are blended
into one undistinguishable mass as far as anatomical configuration and
sharpness of outline are concerned. The interior of the larynx, on the
contrary, is as yet unattacked by the disease, neither false nor true vocal
cords have suffered any change, and the latter may be seen, of normal
figure, moving freely during phonation.
Fig. 1.
374
Lefferts, Lupus of the Larynx.
[April
Such being the condition, the question of diagnosis at once forces itself
upon us. Is the view that I have taken as to the nature of the morbid
process correct or not ? The question is of importance and interest, more
perhaps from a scientific point of view than for any special bearing
that it may have upon the question of treatment. Its difficulty of solution
will be conceded, and I indulge in the hope that perhaps my description
of the appearances, as I have observed them, may be of service in differ-
entiating future cases from other diseased conditions of the larynx, which
laryngeal lupus so much resembles. Now wherein does the difficulty lie,
and what disease presents the nearest pathological type, as far as laryngo-
scopy appearances go, to lupus? I answer unhesitatingly, laryngeal
tuberculosis, and believe that in the latter we have the great stumbling
block to a correct diagnosis of the former. Both, to particularize, are
characterized by general hypertrophy of the laryngeal tissues, mainly of
the epiglottis and posterior portions of the laryngeal vestibulum, both
present the same superficial worm-eaten ulcerations, especially in the earlier
stages ; both have as symptoms a profuse muco-purulent discharge, a sense
of obstruction, of tumefaction in the throat — the dysphagia, the cough,
and the same general laryngeal distress. Let us now see wherein they
differ if they do, and if the differences are so marked as to be invariably
diagnostic. The first question I can answer from the results of my expe-
rience and that of others, as found recorded in surgical writings, and point
out certain variations in the general picture — variations that future ob-
servation may demonstrate to be constant, and therefore reliable and
diagnostic. Upon the second I have considerable doubt, and must con-
fess that the clinical history of the affected individual would have much
weight with me in determining my opinion ; in other words, I should
want to see evidences of a lupus of the cutaneous surface to make assur-
ance doubly sure. I should want to be able to exclude syphilis and
phthisis from the patient's history, to confirm me in my view as to the
pathological nature of his laryngeal lesion. Can Ziemssen, for instance,
positively assert that the case which he reports as one of lupus of the
larynx {ibid) was unquestionably so? There was ulceration of the epi-
glottis, it is true, and perhaps of an uncommon character, but nothing
more. Neither lupus of the skin, nor of the pharynx was present ; on
the contrary, the patient, a girl of twelve, looked fresh and blooming.
Syphilis he excludes, and justifies the exclusion by the failure of potash
to control the disease. Tuberculosis he does not take into consideration,
at least no mention is made of it, and on the basis of an ulceration of the
epiglottis with numerou^granulation nodules in the immediate vicinity is
made the diagnosis of lupus, a diagnosis which he acknowledges was
arrived at with difficulty, owing to the absence of any evidence of lupus
of the skin, but which he considers was established by the course of the
1878.]
Lefferts, Lupus of the Larynx.
375
disease, and the results of a local treatment by cauterization. In this I
must differ with him.
How now do phthisis and lupus of the throat vary, and what are the
variations ? In attempting to poftit out differences I must proceed with
caution. Our experience of the disease termed lupus of the larynx is not
as yet extensive, perhaps never will be, and subsequent observations must
favour or disprove the truth of the points to which I am about to call
attention.
First, then, the condition of the pharynx as I have described it in my
patient is certainly met with in no disease except, perhaps, very rarely
in advanced cases of general tuberculosis ; and even in these there is only
a simulated appearance. In them we do not find the distortion, and the
very marked fleshy granulations dotting the parts, the extensive erosion,
nor the hypertrophy of the mucous follicles at the base of the tongue, and
the fleshy nodules in the same locality. The condition of the pharynx
then, it seems to me, is, to say the least, very suggestive. Again, do we
find in phthisis of the larynx the peculiar appearance of the epiglottis that I
have called attention to in my case? an appearance which resembles perhaps
a raspberry more than anything else, it is so nodulated, so covered with
hard granulations. All the other points, the erosions, ulcerations, and the
hypertrophy are common to both diseases, but the epiglottis in laryngeal
phthisis is always free from hard granulations, and uniformly hypertrophied,
even when its surface is broken by the slight losses of substance ; the
large, deep, and extensive ulcerations of the part, which have been met
with in all the cases of lupus so far fully recorded (with the exception of
mine), are certainly most infrequent in tuberculosis of this organ. Re-
garding the remaining portions of the larynx, as I see them in the present
stage of my case, I say nothing ; the appearances are not diagnostic, and
might with equal justice be taken as an indication of either disease. If
we now go one step further (and it is a step which, as I have said, I con-
sider that we must take), and after rigid inquiry and exhaustive examina-
tion are able to exclude both pulmonary phthisis and constitutional syphilis
from the patient's history, but find evidences upon the cutaneous surface
of lupus, no matter how slight, are we not justified in making the diagnosis
that we have, viz., lupus of the larynx? Other diseased conditions of the
organ — carcinoma, oedema, etc which might possibly be confounded with
the one under consideration, I do not now dwell upon ; their general cha-
racteristics, laryngoscopic appearances, symptomatology, and clinical his-
tory render them, as a rule, easily recognizable.
Syphilis, however, presents greater difficulties, and deserves a word.
The epiglottis, as is well known, is a favourite seat for the tertiary mani-
festations of the disease in the throat, which may likewise involve the
pharynx ; but if it do, its presence and its sequela? certainly vary widely
from the description of the pharynx that I have given above as occurring
376 Lefferts, Lupus of the Larynx. [April
in lupus. Regarding the larynx, it is only necessary to call the reader's
attention to the character of the lesions in order that he may appreciate
the differences which would render a diagnosis between the disease- one
of no peculiar difficulty in the great majority of cases. A tertiary syphi-
litic ulcer of the epiglottis is usually single, has more or less of a circular
form, with sharp, sometimes strongly elevated margins; a deep base,
covered, it may be, with a tenacious yellow secretion ; and, finally, it is
surrounded by an areola of tumefaction, which is limited to the imme-
diate vicinity of the ulcer itself, and is solely dependent upon the amount
of inflammatory action which it has excited. In other words, there is no
general hypertrophy of the tissues, no simple erosions, worm-eaten and
superficial, no hard granulation tissue, no fleshy excrescences, as we see
them in lupus. Finally, aside from the history of the case, we have other
evidences of the disease in various parts, and the result of an anti-
syphilitic treatment to guide us; certainly, together, a strong array of
facts, incontrovertible in diagnostic worth if they occur in a patient who
presents no evidences of lupus upon his skin.
Upon the questions of prognosis and treatment I have nothing new to
add. An experience derived from careful observation alone can decide
the points which are to-day unsatisfactory and incomplete. The " termi-
nation of lupus in the mucous membrane, as well as in the skin, is in
ulceration, with progressive destruction. The healing of defects with an
indurated cicatrix is seldom lasting, for usually new miliary eruptions,
new lupus nodules, consisting of a young, generally very vascular granula-
tion tissue, containing little round cells, and originating in proliferations
of the connective tissue, and not of the epithelium, break forth in the
immediate vicinity of the scar."1 ( Virchotv, AusjJi'tz. Paid.) With such
an outlook, prognosis can but be unfavourable.
Our treatment of the laryngeal complication is confessedly more or less
empirical, being founded alone upon what experience has taught us in
regard to the management of the lupus of the cutaneous surface. I can
find but two cases (Tiirck, Ziemssen (?) ) upon which to base any conclu-
sions regarding the effects of therapeutic procedures. In these ''either a
partial retrograde development of the neoplasm, or an arrest of the pro-
cess and partial atrophy of the new growth" is stated to have occurred
under a prolonged treatment by large doses of cod-liver oil, and destruc-
tion of the lupous nodules by means of strong cauterizations with the
nitrate of silver. In my case, the latter were so badly borne that they
were of necessity discontinued, and a much milder treatment, in which a
modified Lugol's solution and sedative applications played an important
part, substituted, to the great comfort and relief of the patient, but without
amelioration of the local pathological changes. The time, however, in
1 Ziemssen, Cyclopoedia, vol. vii.
1878.]
Lefferts, Lupus of the Larynx.
377
which they have been employed is comparatively short, too short to jus-
tify any deductions as to their success or non-success in arresting the
disease. I therefore reserve the results of my experimentation, for it
amounts alone to that, for future publication, when I likewise hope to
give the facts developed by the investigations upon which I am now en-
gaged, regarding the frequency of the laryngeal complication in lupus.
In conclusion, let me reiterate, with Von Ziemssen, "that there is
urgent need of further observation both with regard to laryngeal lupus
generally, and in particular with regard to its therapeutics."
Conclusions 1. Lupus of the larynx, from our present experience of
it, must be regarded as a rare disease.
2. Seven unquestionable cases and three doubtful ones are alone upon
record ; in all of the former, lupus of the cutaneous surface (face, neck,
back, arms, etc.) coexisted.
3. The diagnosis may be made from the peculiar, and perhaps charac-
teristic appearance of the pharyngeal parts, the nodulations, fleshy
granulations, and ulcerations of the epiglottis primarily and specially,
the clinical history of the patient, and the concurrent signs of lupus of
other parts.
4. The differential diagnosis is not unattended with difficulty. Laryn-
geal tuberculosis, syphilis, and carcinoma all present certain points of
similarity to lupus, especially the first named. From the two last, and
likewise from oedema glottidis, chronic follicular laryngitis, etc., it may
readily be distinguished. The pharyngeal appearances, the peculiar
aspect of the epiglottic lesions, and the extent, location, and pathological
character of the concomitant ulcerations, together with the clinical his-
tory and manifestations of a cutaneous lupus, will serve, if care be taken,
to distinguish laryngeal lupus from laryngeal phthisis, as in the latter
affection all of the above-mentioned signs fail, and are replaced to a great
extent by others, which are certainly different, and generally regarded as
diagnostic. These points are alluded to in detail in the article.
5. The prognosis is unfavourable, and the site of the disease at the
entrance of the air-passages, manifestly exercises a marked influence as
regards danger and duration.
6. Treatment is more or less empirical, being based at present alone
upon what experience has taught of the treatment by destructive agents
of the concomitant affection of the skin. Nitrate of silver and cod-liver
oil appear to have been of service in certain instances, while in others
they have failed ; in still others a sedative and entirely unirritating treat-
ment has succeeded best, if not in effecting a cure, or even arrest of the
disease, at least in giving marked relief. Upon this question further light
is earnestly to be desired.
6 West Thirty-third Street, New York.
No. CL — April 1878. 25
378
Robinson, Paralysis of Vocal Cord.
[April
Article VII.
A Case of Paralysis of the Abductor Muscles of the Vocal Cords
probably due to sclerosis, affecting particularly the nerve
Roots of the Spinal Accessory in the Medulla Oblongata and
Spinal Cord. By Beverley Robinson, M.D., Visiting Physician to
Charity Hospital ; to the Manhattan Eye and Ear Hospital, etc.
J. F., set. 44, married, special R. R. detective, presented himself at my
throat clinic of the Manhattan Eye and Ear Hospital, October 27, 1«77.
In 1861, patient had " swellings" in groin, and two or three sores on pre-
puce, which were readily cured. In 180(5, had again excoriations on
prepuce, and a chronic urethral discharge ; was treated with injections
and inunctions of mercurial ointment for presumed constitutional dyscrasia.
In the subsequent history, however, there are none of the usual syphilitic
accidents, except an attack of ulcerative sore throat in 18G8, which was
believed to be of specific nature.
From 1868 to 1873, patient was well, although enduring great fatigue
and exposed to rapid and considerable changes of temperature. In the
fall of 1873, he became very much broken down by over-work, and suf-
fered from pain and weakness in the back, weakness in the limbs, and
partial loss of power in legs and feet, viz., stubbed his toes against slight
obstructions, locked one foot behind the other, heel of boot dragged and
caught on the steps in going down stairs, etc. Some of these symptoms
have disappeared (stubbing toes, locking feet) ; others remain, but have
somewhat improved (pain in lumbar region of spine, dragging of feet) ;
and the following analogous ones have manifested themselves : 1. Partial
paralysis of bladder, shown by dribbling of urine, and loss of force in
stream. 2. Loss of sexual power, which has come on little by little during
the last three years, so that at times there is total incapacity to accomplish
coitus. 3. A wavy, unsteady motion whilst walking — a sort of rocking on
the feet, as if the soles of his shoes were round instead of flat. 4. A de-
fect in writing, i. e., the letters and words are not so correctly formed and
placed as formerly, and there is a jerky motion of the pen ; many times
the last letter of a word will be made imperfectly, or the same letter written
twice. 5. Depression of general nerve force, and unusual exaggerated
excitability. 6. Difficulty in swallowing the last mouthful of any solid
food. Has never been intemperate, and never used tobacco to excess.
Until lately, he has been moderately successful in his profession. Unfor-
tunately, for several years his married life has been unhappy, and he has
many domestic troubles. His brain is lucid, and his eyesight normal.
Difficulty of breathing, and partial loss of voice (hoarseness), were observed
two years ago for the first time, and in this regard he has never improved.
During the past month, condition of throat has rapidly grown worse, until
now his breathing becomes oppressed upon slightest exertion. Has had
two attacks of intense dyspnoea latterly, each lasting ten minutes, and
brought on by a paroxysm of cough. They were so severe that, whilst
they lasted, he thought he would die. Sleep disturbed by obstructed respi-
ration and frequent cough.
Physical examination of larynx shows great narrowness of glottic open-
ing during inspiration. The left vocal cord is nearly immovable, and
remains close to the median line when he draws his breath ; the right
1878.]
Robinson, Paralysis of Vocal Cord.
379
vocal cord has slight mobility at this period, although much impaired in
its functional power. The vocal cords and ventricular bands are red and
somewhat swollen. No oedema, or ulcerations of orifice, or interior of
larynx, and no deformity of its parts. After inspection with the laryngeal
mirror, there are painful and prolonged paroxysms of cough, followed by
very noisy inspirations. Patient during this period suffers great anxiety.
R. Gilbert's syrup of mercury gr. t. in d.); garg. potass, chlor. ad
saturand.
Oct. 29. Ordered in addition, potass, iodidi, gr. v, t. in d. ; increase by
ten grains each successive day.
Nov. 4. Less whooping and coughing ; no more serious strangling ;
voice somewhat less hoarse in-doors ; when he goes into open air hoarse-
ness increases rapidly, and difficulty of breathing, with shortness of breath,
comes on after very slight exertion ; throat seems more sore, raw ; the
act of swallowing gives him pain, especially since he has taken iodide of
potash in increasing doses ; at beginning of deglutition has some difficulty
of performing the act, afterwards it becomes easier ; swallows liquids or
solids equally well ; is now taking 100 grs. of iodide of potash and \ gr.
of biniodide of mercury in twenty-four hours. Ordered inh. tinct. ben-
zoini.
5th. Nose and throat so much choked with mucus that patient can
scarcely breathe ; paroxysms of cough, to expectorate it ; tears throat pain-
fully ; chest constricted ; can't take a full breath ; bowels somewhat loose.
Stop iodide of potash ; continue hydrarg. biniod.
8th. Breathes better since iodide was stopped ; complains of sudden
cramps at times in muscles of neck ; for some months bowels regular ; P.
84; R. 14, slow, regular, and deep; vocal cords scarcely separate at all
during inspiration, and chink of glottis is very narrow in a permanent
manner (only two or three lines transversal opening) ; the inflammatory
appearance of the vocal cords and ventricular bands has improved. Re-
peat mercury and iodide of potash (5 grs. t. in d.)
l'2th. Cough frequent and harassing; moderate amount of sputa, frothy
and purulent.
Auscultation of Chest Lungs perfectly healthy, in so far as physical
signs can determine it ; cardiac irritability ; no signs of aneurism, or other
intra-thoracic tumour ; medication stopped.
17 th. There is now complete paralysis of the abductor muscles on
either side ; during ordinary inspiration the vocal cords do not move
either towards or away from median line. In forcible and deep inspiratory
efforts they approximate slightly, and thus augment the already narrow
glottic opening. An application has been made each day to the larynx of
ferric alum (Slj-^j) without increasing stridor or dyspnoea, or causing
cough.
The reflex sensibility, in fact, of the laryngeal mucous membrane is
nearly abolished.
19^. Pulse 90 ; temperature normal ; patient suffers much from dyspep-
sia ; occasional cramps in the muscles of the neck, especially the sterno-
mastoids; has considerable uncertainty in the movements of his hands,
and whenever he attempts to touch a particular spot, or take hold of an
object, is unable to direct his movements with accuracy. His writing is
notably imperfect, and he is obliged to use his pen in a special position.
He writes with a quick succession of interrupted movements. He com-
plains of a feeling of numbness on the left side of the chest anteriorly ;
880
Robinson, Paralysis of Vocal Cord.
[April
sensibility of his side about the same — sight normal ; power to articulate
words accurate, his disability depending solely upon a hoarse voice, which
is now always present. R. Iodoform to larynx; Argent, nitratis, gr. \
t. in d. sumend.
20tk. No external tumour over cervical region of spine ; no pain on
moderate pressure; has marked increase of saliva, which makes him swal-
low frequently, but it does not run from mouth ; lips can be pressed to-
gether as well as formerly; complains of pains during last month in feet,
knees, and ankles, and lower extremities generally. Eyes examined by
Dr. David Webster, of New York city, with the ophthalmoscope, and
"optic nerves were found hypercemic, as shown by too numerous blood-
vessels, though none seem to be enlarged." Pupils equal and react well
to light. Palatal muscles contract when called upon to exert voluntary
movements, as in saying "e" and "eh" with mouth open. Can, however,
tickle uvula and pharynx almost with impunity without causing reflex ac-
tion of retching. R. Galvanic current to neck (5 cells of 24 cell battery.
Galvano-Faradic Co.. N. Y.) Repeat argent, nit.
23c?. Weakness of lower extremities increasing ; repeat galvanism.
28th. Has passed during past ten days large quantities of clear urine:
heart beats irregular and intermittent. Repeat galvanism every other
day. R. Tinct. cinchona? comp. 3j? t. in d.
30th. Stiffening of left ankle-joint : legs bend under him in walking;
erratic, darting, shooting pains in head and over whole body. Applica-
tion of argent, nitrat. pulv. (gr. xv-5j bismuth) to larynx produced in-
tense spasm, allayed by inhalations of ether.
Dec. 3. Complains of pains in both knees and left ankle (joints not
swollen); also of pains in heart and head. Pulse ranges from &5 to 100;
return of spasmodic rigidity of muscles of neck ; interrupt argent, nit. ;
continue gal vanism .
5th. Lancinating pains yesterday in calf of left leg; lasted about half
an hour; had analogous pains in calf one month ago; they came on at
intervals during three or four days; before or since that time till now does
not remember to have had pains of similar description. These pains re-
semble the insertion of a sharp instrument gradually made into the flesh
from above downwards ; each pain lasts about thirty seconds, and another
follows it at about a like interval ; plantar sensibility, equal and normal
on both sides. Has passed about four quarts of urine daily during past
three weeks ; has a feeling of stricture around abdomen ; nervousness of
hands is more in left than right. R. Phosphide of zinc, gr. -jL t. in d. ;
galvanism.
10th. Urine examined; no sugar and no albumen. Repeat phosphide :
mild faradic current to neck ; condition not improved.
Remarks. — The case just detailed offers many points of interest to the
neurologist, as well as to one interested in rare forms of laryngeal trouble.
Here is an instance of a patient whose brain is clear and who has no
physical evidence of intra-thoracic lesion, with absolute paralysis of the
crico-arytenoidei postici muscles. There is nothing in the larynx which
can satisfactorily explain the condition observed, and no compression
irom the existence of a tumour of the neck, even though it were detected,
would at all account for the phenomena so fully described in the narration
of my case. I have located without hesitation the primary lesion in the
1878.]
Robins ox, Paralysis of Vocal Cord.
381
spinal axis, and I consider the upper cervical region of the cord and a
portion of the medulla oblongata to be especially affected at the time of
writing. I have little doubt, however, that the lumbar region of the
spinal cord is the seat of nerve degeneration, although it appears to me
that there is now some improvement in the local condition at this level,
over what existed a year or two ago, when there was more paralysis of
the bladder, and more complete loss of sexual vigour than now exists.
The nerve alteration of the medulla oblongata and of the spinal cord pro-
bably exists in patches, for I have been able to note no symptoms which
show that the upper cervical nerves, or the facial and hypoglossal nerves,
are at all implicated. The trigeminal nerves are perhaps slightly af-
fected ; witness the loss of reflex irritability of the post-pharyngeal wall.
The optic nerves are nearly intact. Briefly, therefore, the lesion what-
ever it may be, in so far as the intra-laryngeal trouble is concerned,
attaches itself evidently to the root origins of the spinal accessories and
the pneumogastrics. Xo other hypothesis, in my opinion, is sufficient to
explain the symptoms. What is the nature of this lesion ? Is it syphi-
litic ? I do not believe it is : 1, because the syphilitic history is doubtful
in the extreme. 2, because my patient has had no well-defined specific
phenomena of secondary or tertiary character, unless we accept as such
a single attack of ulcerative sore throat " so called." 3, because anti-
syphilitic treatment has had no influence upon the actual march of the
disease.
Is the lesion one of sclerosis, or one of atrophy, or complete disappear-
ance of nerve cells, due to some obscure cause, of which we do not as yet
know the entire influence or effects ? The first notion appears to me the
correct one. In fact many symptoms point to the existence of locomotor
ataxia, i. e., the swaying gait, the inability to preserve equilibrium with
eyes shut, the peculiar manner of writing, and on two occasions lancinat-
ing pains felt in calves of legs. The only two symptoms which point to
Duchenne's disease (labio-giosso-laryngeal paralysis) are the increased
amount of salivary secretion and the difficulty of swallowing the last ali-
mentary bolus. The loss of reflex sensibility of the pharynx and larynx
appear to me negative signs, in so far as the precise nature of the lesion
is concerned.
There have been several cases of Duchenne's disease in which the pa-
tient has died without presenting evident signs of laryngeal paralysis ;
when laryngeal paralysis was present it was a loss of action in the adduc-
tors and not the abductors. Yocal sounds were rendered difficult — articu-
lation was very greatly interfered with, and at times complete aphonia
existed. In my case it will be remarked that except for the moderate
hoarseness which exists, articulation is perfect. The pronounced laryn-
geal symptoms of my case are dyspnoea and fits of strangling. The cords
can approximate in phonation, but they cannot separate during respira-
382
Beane, Rectotomy in Stricture of the Rectum. [April
tory movements. We see at once the imminent danger the man is in
from asphyxia. A sudden emotion, an acute cold, might occasion death
at any time. I have notified him of these very possible, and even proba-
ble, contingencies. And yet I have not wished to urge tracheotomy, for
whilst it is the only thing to be done in an emergency and when the
man's life seems absolutely to require it, until that time I am loth to per-
form it. I feel satisfied, when once the tube is introduced, he will always
have to wear it. I shall postpone this dark day for him so long as possi-
ble, in the hope that medication may be of some avail. If this patient
dies within a brief period, it will of course be most interesting to know
what changes have taken place in the medulla and cord, and how far, too,
the abductor muscles of the glottis have become atrophied owing to pro-
longed inaction.
So far as I have been able to discover there is no recorded case of loco-
motor ataxia in which the laryngeal affection has been so accurately
determined as the one I have reported. For this reason, if for no other,
it is of great interest.
Article VIII.
Case of Specific Stricture of the Rectum ; Antero-posterior
Linear Rectotomy ; Recovery. Remarks ox the Operatiox. By
Frank Dudley Beane, A.M., M.D., of New York City.
Mrs. B., set. 30 years, American, married, no children, no abortions,
family history good. Has indulged in alcoholic stimulants, more or less
daily, for the past eight years. Leucorrhoea eight years ago, which con-
tinued more than a year ; since has been free from all vagino-uterine
trouble. No history of uterine, peri-uterine, or abdominal affections.
Denies venereal disease. Close questioning fails to develop the history
of the ordinary "secondary" manifestations; but for the past year has
been present on both legs, lower half, a papular, copper-coloured erup-
tion, intermingled with copper -coloured and brownish-yellow depressed,
circular cicatrices. Suffers rheumatic (?) pains in the lower limbs at
times, not constantly. Never treated for eruption. Her present disease
began, she thinks, about twelve years ago as a mild diarrhoea; two or
three unformed yellowish stools daily. Following upon this were scyba-
lous, "loose," and bloody mucous stools, increasing tenesmus, anal pain,
nausea, and loss of appetite. General health not apparently much affected.
Present Condition — Apparently well nourished ; urino-genital organs
perform their functions normally; indigestion ("pain and weight");
four or five thin, yellowish, occasionally scybalous stools daily, accompa-
nied by great tenesmus — almost every night obliged to sit upon the vessel
half a dozen times, strain half or an hour at a time, a muco-purulent dis-
charge the only result. External hemorrhoids and loose cutaneous anal
folds. The finger detects, about three inches above external sphincter,
an annular constriction of the rectum, calibre No. 26 (French) urethral
1878.] Beane, Rectotomy in Stricture of the Rectum.
383
bougie. The stricture has a firm, fibrous feel, the tissues in the vicinity
quickly shading off to normal resistance ; no irregular, nodular, stony
induration to be detected. Sims's speculum not introduced, because of
the resistance and pain produced by the examining finger.
July 23. Removed the hemorrhoids and loose anal folds. Placed her
upon hydrarg. protiodid. gr. J morn and eve ; ordered her into the coun-
try to recruit her strength for the operation of linear rectotomy, which I
advised, she and her husband accepted, both having declined gradual di-
latation, by no means strenuously recommended. To cease the use of
stimulants.
Sept. 10. Just returned from the country with bowel trouble increased.
To take quinise sulph. gr. ij, in pil., after each meal, a substitute for the
above pills.
Dec. 2.1 Dr. James R. Wood examined patient to-day, confirmed my
diagnosis, and recommended the proposed treatment. At his suggestion
placed her upon potassium iodide gr. x, thrice daily, as a specific tonic.
On the 4th inst. was obliged to discontinue iodide on account of nausea
and diarrhoea; substituted quinine sulph. hydrarg. protiodid. gr. viij,
ext. nucis vom. gr. x. M. f. pil. xl. Sig. one after each meal. On same
day passed No. 28 (French) urethral bougie through the stricture, re-
tained twenty minutes; on the 13th, No. 28, then No. 30 ; on the 20th,
No. 30, then No. 2 English rectal bougie; 27th, No. 3 ; 31st, No. 3, fol-
lowed by No. 4, the latter causing intense pain ; at every sitting instru-
ments retained five minutes each, causing considerable pain. Great
improvement as regards tenesmus and discharge since using the bougies.
Operation. — Jan. 2, 1876. Patient thoroughly inebriated by brandy,
former experience having taught me that complete anesthetization could
not be induced by ether unaided. Assisted by Drs. J. S. Fitzgerald, N.
S. Westcott, B. C. Mclntyre, and G. A. Evans. Digital examination of
the uterus and appendages found nothing abnormal. With difficulty car-
ried my index finger through the stricture ; found mucous membrane
above roughened and thickened, but slight amount of ulceration. Blood
followed the withdrawal of the finger. Ruptured external sphincter, a
small rent in the anal mucous membrane occurring. Sims's largest
speculum showed beautifully the location of the contraction, with its
shining, fibrous appearance. Dr. F.'s finger being in the fornix vagina,
I passed a probe-pointed bistoury partially through the stricture, when
the speculum became displaced, and was obliged to withdraw the knife.
A second attempt failed for the same reason ; I had the speculum with-
drawn. With my left index as a guide, I passed the knife completely
above the contraction, and by three sweeps cut completely through the
tissues anteriorly ; they creaked under the knife like cartilage. Con-
siderable hemorrhage followed ; incision carried to a depth of about three-
quarters of an inch. Reintroduced the speculum, brought the posterior
part of the stricture fully to view, and divided with a scalpel all the coats
of the gut, even through the post-rectal cellular tissue, to the length of
two or more inches in the median line, the tissues grating as before. In-
creased hemorrhage ; removed speculum, passed index, found quite a little
band at the most superior margin of the once structured gut, which I freed
by the knife ; still above this another slender band, which I tore with my
finger. Hemorrhage very free ; filled rectum with ice, and in five
1 An examination of her urine on November 24th showed normal amount, colour,
reaction, etc., sp. gr. 1025, negative to tests for albumen and sugar.
384
Beane, Rectotomy in Stricture of the Rectum. [April
minutes all flow had ceased. Soon after gave an enema, which washed
away blood, feces, etc. ; then anointed the cut surfaces with carbolized oil
(1 : 10), and introduced the wire rectal plug, smeared with the same sub-
stance. Operation lasted about fifty minutes.
4.30 P. M. (three hours after operation). Pulse 112, full, soft; temp.
99.5° F. Has vomited.
9.30 P. M. Pulse 120, small ; temp. 103.6° F. ; respirations 28, regular.
Has vomited and retched much. Thirst extreme, but water and ice im-
mediately rejected. Complains of some rectal pain.
11.40 P. M. Hypodermic gr. ^ morphia. 12 M. Sleeping.
3c?. 8 A. M. Slept some ; awakened by thirst, which was terrible,
and only controlled by moistening the lips every few minutes. Rectal
plug removed at 2 A. M. on account of tenesmus and heat about the parts.
No hemorrhage had occurred. Little or no pain. Pulse 132, small, soft,
regular; temperature 101° F. ; respirations 14. Has retained two tea-
spoonfuls of beef-essence this morn.
9 o'clock. Washed out bowel with sol. potassae permang. (gr. x ad Oj),
which brought away a few coagula and feculent-smelling, dark liquid.
Anus swollen and tender. Unable to urinate since the operation ; just
drew off fgiv normal urine. R. Quinise bisulph. gr. ijss, tr. digitalis
nj/j, liq. morph. sulph. (Magendie) ttijv, in haust. tert. hor. sumend.
Cold beef-essence equally often. Ice ad libitum. Liq. morph. (Mag.)
gtt. x as often as required for pain.
9 P. M. At 4 o'clock pulse 120 ; temp. 104.2° F.; respiration 14 : 10,
regular. About the same hour passed nearly a pint of darkish urine ;
rectum syringed out as in morning, bringing away a little normal feces.
Mixture causes nausea. Thirst abating. Perspires freely. Slight ten-
derness and pain in hypogastrium. Temp. 102.8° F.
10th. Nausea and vomiting occasionally till the 4th inst., then ceased.
Eve of the same day menses appeared, ceased the afternoon of the 6th inst. ;
preceding and during the flow moderate hypogastric pain and tenderness.
Natural, formed stool caused by enema the 5th inst., and daily since.
Till that date enemata invariably caused vomiting and retelling. Mor-
phia each night has caused sleep in naps. Beef-essence, milk, and two
milk punches daily have been the diet ; gr. x Hawley's pepsine with each
meal (taken about every three hours). Morphia for pain and sleep, from
gr. ss : jss daily. Commenced taking the 7th inst., R. Hydrarg. protio-
did. gr. x ; quinias sulph. 3^s ; pulv. opii gr. viij ; ext. gent. q. s. f. pil.
xxx. Sig. one thrice daily. On the 8th digital examination revealed
full calibre of bowel, no hardness posteriorly (great tenderness, however),
incision gaping ; anteriorly, callous edges of gaping incision.
To-day introduced bag No. 3 of Molesworth's dilator, filled to circum-
ference of 3-J inches, retained five minutes ; caused much pain and tenes-
mus. Vomited and retched during retention. Dysuria ; buchu and bel-
ladonna therefor. Mucous discharge from rectum.
11th. For first time a spontaneous natural, consistent stool : much pain.
Solut. potassae chlorat. O'.j ad Oj), instead of permang. solution, in future,
after each stool or at least once daily.
12th. Dilator No. 4, to circumference of 5 inches, retained two minutes ;
pain intense : vomiting, and tremor of muscles of whole body.
17th. Daily stool by aid of aperient pill at bedtime. Dilator No. 4, to
circumference of 5^ inches, retained ten minutes ; vomited ; less pain. On
18th began sitting up in chair two or three or more hours daily. In
1878.] Beane, Rectotomy in Stricture of the Rectum.
385
addition to pills to take gr. ij quinise bisalph. thrice daily. Anal fissure
troublesome ; apply R. Hydrarg. protiodid. gr. x; unguent, belladon. Jj.
M. Sig Thrice daily.
22c?. Began upon solid food the 13th. Quinia discontinued 20th inst. ;
caused nausea. To-day dilator No. 4, to circumference of inches, re-
tained fifteen minutes. Operation still less painful. No vomiting, no
retching.
Feb. 2. Resumed solid meals on the 28th ult. Morphia discontinued.
To-day dilator No. 4, to 4 inches, leakage by side of piston ; retained
fifteen minutes. 5th inst. Anal fissure healed. Walked a block to-day.
8th. Digital Examination Anteriorly : A little induration on either
side of the incision, extending laterally about half an inch, more diffused
than sharply defined : perfect patency of the incision. Natural feel above
and below old seat of stricture. Posteriorly : Deep sulcus of more than
two inches in length ; tissues thrown forward in folds as though tied back
along the centre by a cord ; tissues thickened from a point above internal
sphincter as far as the finger can reach. No traces of former contraction.
Tenderness considerable along the sulcus and its immediate vicinity.
Whole canal perfectly patent.
15th. Discontinued mercury — quinia pills two days ago. To-day dilator
No. 4, to 5^ inches, retained ten minutes. Quinia for appetite. Discon-
tinue chlorate enemata, but for a couple of weeks hence use salted enema
after each stool.
May 9. A slight bloody discharge for a day and a half followed the last
use of dilator. On March 7th used dilator, to 5f inches, retained eight
minutes; great pain. About April 10th a specific tuberculous eruption
over right patella, with irregularly-diffuse subcutaneous gummatous swell-
ings along the inner aspect of the same thigh, extending from the knee
upward for about three inches, declared itself. General health greatly
improved. Put her upon potassium iodide (gr. xv), and mercury proto-
chloride (gr. ^) thrice daily. Had, usually, one or more daily stools.
Was obliged to discontinue the above remedies because they caused con-
siderable enteric disturbance. Has been annoyed ever since by frequent
involuntary discharges of yellowish-brown (feculent) fluid ; slight muco-
purulent discharge still continues. Has had no tenesmus since the opera-
tion ; bowels move their contents by two or three successive stools at one
or two hours' interval.
Digital Examination. — Under ether : Anterior incision healed ; a firm
cicatrix and a little surrounding induration alone to be detected. Little
or no deposit in the recto-vaginal space. Posterior cicatrix hard ; the
lateral remains of the old stricture very much softened.
Per Speculum — Large Sims's speculum passes with ease. Anteriorly
there is a healthy cicatrix ; at, the upper limit of the incision a minute
eroded spot. Tissues otherwise apparently healthy. Slight erosion and
an exuberant granulation at the upper limit of the incision posteriorly.
No apparent tendency to recontraction. External sphincter has partially
regained its p^ower. Introduced dilator No. 4, to 5^ inches, retained half
an hour. Digital examination, after removal of water-bag, found the
mucous membrane, and underlying tissues, about the old contraction, soft-
ened. To apply, by inunction, hydrarg. oleat. (6 per cent.) gtt. xx,
morning and evening. R. Iodoformi, 3ij ; acid, tannic. 9j ; pulv. ipe-
cac. 5j ; pulv. opii gr. x ; ol. theobrom., q. s. ; f. supposit. xij. Sig
One daily, after a stool and washing out rectum by salted enema.
386
Beane, Rectotomy in Stricture of the Rectum.
[April
July 9. Had been on potassium iodide (gr. x) and hydrarg. protochlo-
ride (gr. thrice daily, till the 2d inst., for the knee-thigh eruption,
which had rapidly increased in extent and severity after the last use of
the dilator, when I substituted starch iodide (one teaspoonful, in milk,
after breakfast and tea) for the potassium salt. Two or three daily natu-
ral, but partial, evacuations, due to want of tone in the bowel, to fully and
at once expel its contents. The eruption is much improved at present,
and still fading away. The starch does not affect the bowels unfavourably,
as did the potassium preparation. General health better than for years.
Aug. 14, 1877. Has been under treatment since last report more or
less constantly for the knee eruption. She has taken the iodide of starch
(1:2 teaspoonfuls twice daily) ; protiodide or protochloride pills; usedprot-
iodide of mercury and oxide of zinc ointments for the knee, which has
fluctuated between better and worse due to irregularity in treatment, in-
dulgence in alcohol, and general neglect. Whenever the starch iodide
was taken regularly for a month or six weeks the knee eruption was pro-
nouncedly improved ; in fact, in Aug. 1876 it was almost gone; neglect
and abuse of the system caused a rapid return. Last December saw the
last of her rectal discharge, since when her stools have been of natural
consistence and but one or two daily, except when green fruit has been
eaten — not seldom the case. Constipation has occasionally needed an
aperient. No tenesmus till within six iveeks, very slight. General health
has been most excellent — since January has weighed more than ever
before. In spite of my advice (dating back to last October) she has re-
fused to grant a digital examination till now.
Digital examination, under ether, reveals recontraction ; anteroposte-
rior diameter equal to about an inch, perhaps an inch and a quarter — a
large sized thumb may be passed easily. Recontraction greater anteriorly
and laterally than posteriorly. Edges hard, but smooth ; not as hard as
before the operation, however. The tissues lying immediately adja-
cent to the annular ring are perfectly soft and natural. No ulceration.
Introduced dilator No. 3 and filled to a circumference of 3^- inches only,
due to leakage behind the piston ; however, I had only intended to dilate
to 4-| inches circumference, inasmuch as, the patient being anaesthetized,
I had no guide to the proper amount of tolerable distpusion. I also calcu-
lated on a repetition of the dilatation at the end of a week, again and
again if necessary, and wished to be over-careful at first. Retained the
dilator half an hour. Afterward found the tissues much softer to the
touch, and the canal uniformly dilated to the proportionate diameter. The
knee is steadily improving under potassium iodide (3li : 3"j m 24 hours),
which has been given lately for a severe attack of trigeminal neuralgia,
lasting now more or less constantly for six weeks.
Sept. 18 — The usual remedies have been " pushed" in vain, but quinia,
in gr. xv doses thrice daily (per rectum, on account of irritable stomach),
has conquered this severe attack of neuralgia. The knee is looking bet-
ter than for a year past ; induration greatly diminished, natural colour
supplanting the blue and copper-coloured skin. General health impaired
by this long-continued attack of neuralgia. Dilatation still declined.
My connection with this case ceased about the first of November follow-
ing. Despite all remonstrance, I could not obtain another physical ex-
amination or the patient's consent to following up local treatmentc
Remarks. Etiology On account of the high situation of the stric-
ture and the absence of involvement of the anus or rectum below the an-
1878.] Beane, Rectotomy in Stricture of the Rectum.
387
nular constriction, the cause would seem to have been direct contact of
the specific virus. The absence of vulvo-vaginal cicatrices goes to show
the leucorrhoea as non-chancroidal. Unlike the numerous cases of "ve-
nereal," more properly chancroidal, stricture, where the sequel to the
ulcerative process is contraction of the anus and the immediate superadja-
cent rectum, in this case we have it high up and the tissues below of nor-
mal calibre and resistance. It is specific in its character, as the prece-
dents of a simple form are wanting; cancer is negatived by all the signs;
the character of the existing .syphilitic symptoms points to but one proba-
ble cause.
Treatment All surgeons agree upon the danger of gradual dilatation.
Undoubtedly this danger becomes greater as the size of the instrument
increases. The bowel, in and about the constriction, being in an unnatu-
rally friable condition, a certain degree of dilatation can be tolerated ; but,
carried beyond this point, the tissues easily give way, the rupture of the
bowel ending fatally. This unfortunate result has not been due to bad
manipulation, but to the pathological condition of the gut itself. The
preparatory dilatation pursued in this case was carried simply to the ex-
tent of allowing the finger to examine the bowel just above the seat of
stricture. Had this treatment been followed up to No. 10 or 12 English
rectal bougie, there would have been great danger of rupture. Were
dilatation carried carefully and gradually to a certain point — variable in
different cases according to the nature and degree of the constriction —
treatment by bougies would be comparatively safe. But the degree of
dilatation must necessarily be very limited, the benefit derived merely
reciprocal, prospect of cure altogether out of the question. Antagonistic
to the resorption of the adventitious material, which, to a certain degree,
obtains in all well-treated urethral strictures, stands the fact that frequent
use of instruments here produces resiliency and irritability; after forced
decrease in size, there comes a time when local treatment must be laid
aside and the sufferer's sole relief lies in lumbar colotomy.
Notching the constriction in two or more places, followed by gradual
(or forcible) dilatation (recommended by many high authorities), is even
more dangerous than the simple use of bougies. Dangers like fatal shock,
rupture of gut through its peritoneal investment, formation of abscesses
which may burst into the peritoneum, septicaemia, etc., stare the patient in
the face after such procedure. With very few dissenting voices, present
authorities declare the immeasurable superiority of incision over rupture
in urethral stricture, both as regards danger, tendency to recontraction,
etc.1
The law which governs the pathology of stricture, wherever found, is
1 I am aware of the statistical summary, gleaned from University College Hospital
(of London) Keports, contained in the Lancet, June 23, 1877.
388
Beane, Rectotomy in Stricture of the Rectum.
[April
the same for all parts of the body; and it is not strange that the same
treatment should be equally applicable in one site as in another.
In addition to the authorities quoted by Dr. F. D. Lente in his article
in this Journal for July 1873, Hamilton1 especially warns against forcible
dilatation or incision "in syphilitic cases, particularly when there is a
nodular feel ;" Henry Lee2 also speaks of forcible dilatation deprecatingly ;
Spence3 only countenances simple dilatation; Bryant4 says, "Forcible
dilatation is inadmissible," his treatment being simple dilatation as long as
it may avail, then lumbar colotomy. The leading surgical authorities
condemn divulsion, Henry Smith5 and Verneuil6 alone undertaking the
deeper incisions before Dr. Whitehead's7 case of complete division.
Syme, Velpeau, Nelaton, Bushe, Birkett, Henry Lee, Gross, Van Bu-
ren, Hamilton, Allingham, and Bryant condemn forcible dilatation and
everything more heroic (?) than simple " nicks," followed by gentle dilata-
tion! But rectal surgery is advancing. It may be here remarked, before
proceeding to the examination of the claims of antero-posterior linear rec-
totomy, that electrolysis has proven as complete a failure in rectal as in
urethral stricture.8
In the following table, complete incision, and forcible and simple dilata-
tion, are compared : —
Complete Incision.
1. Complete and clean division;
enlargement of gut to normal
calibre ; wound limited by
the operator's will.
2. Rupture (preferable) or divi-
sion of the external sphincter
ani gives complete drainage,
lessening danger of septicae-
mia, pyaemia, abscess, and
fistula?.
3. No danger of wounding the
peritoneum.
Divulsion.
Rents in the gut cannot
be limited.
Bruising of the tissues
endangers sloughing ;
absence of widely-gap-
ing and cleanly-cut
surfaces tends to the
dangers here enume-
rated.
Great danger.
Simp le Dila ta tio n .
1. Full calibre of
the gut cannot
be restored, ex-
cept in cases of
slight contrac-
tion.
3. Danger of rup-
ture, fatal or
serious.
1 Prin. and Pract. Surgery, New York, 1872.
2 Lectures on Practical Pathology and Surgery, Lond., 1870.
3 Lectures on Surgery, Edinburgh, 1868-1871.
4 Practice of Surgery, Phila., 1873.
s Diseases of the Rectum, 3d Lond. edition, 1871, case p. 49 et seq.
6 Gazette Med. de Paris, Jan. 1873.
' Amer. Jour. Med. Sci., Jan. 1871.
8 See case in Amer. Journ. Med. Sci., July, 1872, p. 118.
1878.] Beane, Rectotomy in Stricture of the Rectum.
389
Complete Incision.
4. Non-requirement of dilating
instruments till shock of ope-
ration and danger of second-
ary inflammations have pass-
ed.
5. Even then no dilatation, but
simple maintenance of the
enlarged calibre by the water-
bag dilator used at long in-
tervals.
Simple Dilatation,
5. Same objection
obtains as in
Divulsion.
Same objection
obtains as in
Divulsion.
Divulsion,
4. Danger of secondary
inflammations, due to
shock, tearing', and
bruising of the tissues.
5. Dilatation must be
continued after the
"nicks" and rupture^
as maintenance of the
enlarged calibre can
only be attained by
almost constant use of
the dilator, due to
6. Tendency to recontraction 6. Great tendency to rapid
showing itself, simple use of recontraction and re-
the bag as a represser ; and, siliency.
in cases of neglect, as a gentle
dilator. Irritability and re-
siliency do not follow the
operation.
Wheat are the objections which may be urged against thorough division ?
Danger from hemorrhage, infiltration, shock, blood-poisoning, and peri-
tonitis. Division in the median line precludes any serious hemorrhage
from the anatomical distribution of the arteries and large veins. Expe-
rience in all thus far reported cases practically proves this a fact even in
pathological conditions of the gut. In no case has infiltration occurred ;
nor is it likely, since frequent antiseptic washings of the surfaces must
tend to prevent it. Shock is no greater than, in many cases, follows sim-
ple dilatation, or any operation of moment ; ether greatly modifies its
effects. Septicaemia is yet to be encountered ; theoretically it must be a
great rarity, since such complete drainage exists, and almost constant
cleanliness of the wounds can be maintained by enemata.
Peritonitis was not developed in Dr. Lente's or Dr. Whitehead's, or in
my case, although the menses appeared the second day after operation in
the latter. Unless wounded or opened during the operation, we should
only fear a circumscribed form, at worst, which, in the majority of cases,
the opium treatment could promptly overcome. There should be no
greater danger, in this respect, than from cutting-operations upon the
cervix and os internum uteri ; and no one can question the necessity for
these in appropriate cases.
Rupture of the external sphincter is much preferable to division, for so
slight a wound as a fissure in this case gave rise to much pain and annoy-
ance. Drainage is just as good, inasmuch as the secretions find a ready
390 Beane, Rectotomy in Stricture of the Rectum. [April
outlet ; it 1ms the further advantage of painlessly allowing the passage of
the dilator without the aid of the speculum.
Operating with the finger as a guide is much superior to the speculum,
especially anteriorly. In one case the feel of the tissues as they give way
is much more reliable than sight, which can. only appreciate the required
depth from a preconceived notion in this regard. With the assistant's
finger in the vagina, and the operator's index appreciating the manner in
which the tissues are giving way under the knife, the recto-vaginal space
shall not be opened or the peritoneum wounded, thus making the anterior
incision as safe (in careful hands) as the posterior. M. A. Muron, in the
^Gazette 31Sdicale de Paris, Jan. 4, 1873,1 says : " One sees that the peri-
toneal cul-de-sac descends very far anteriorly, 4 or o centimetres [about
11 or 2 inchesj from the anus in women, 5 or 6 [about 2 or *l\ inches] in
men ; whilst behind it is found much higher, located as high as 12 or 14
centimetres [about 4| or h\ inches]." The anatomical conformation in
women allows the anterior incision when the provision against too deep
cutting, as above set forth, is acted upon. But what course should be
pursued in males? Being unable to use an assistant's finger, as was done
in the vagina of women, in cases where the stricture is located at or above
two inches from the anus, the anterior incision is dangerous and should not
be undertaken (unless in some exceptional case, which I admit might war-
rant the procedure), since there is great danger of wounding the perito-
neum (to say naught of the bladder, vesicuke seminales, prostate, etc.), and
there is no such chance for drainage of the peritoneal cul-de-sac and tri-
angular space as in the female. Strictures at or below one and a half
inches can admit of the procedure, but usually the posterior incision should
suffice. Dr. Lente2 judiciously answers this question : " In cases of males,
the posterior operation would probably be, as a general rule, all that is
necessary or, perhaps, safe." The posterior incision can scarcely be too
deep or free, since the object is to prevent infiltration, and, at the same time,
to give full size to the gut after the healing process has ended. Packing the
rectum with ice quickly controlled the hemorrhage ; and is far speedier in its
result than the passage of the bell-shaped sponge, so highly recommended.
Dr. Lente proved attempts to tie the divided vessels uncalled for, even a
disadvantage. That no large vessels were likely to be cut led me to be-
lieve ice would be the speediest and most certain haemostatic. The wire-
plug, described by Dr. Lente, is an absolute necessity, being a certain
index to renewed hemorrhage ; it should never be dispensed with. Wash-
ing out the bowel sufficiently often to remove all accumulating matter is
one great element of success in the after-treatment. Thorough washing
after each stool must be pursued, and for the first week at least two (better
1 Amer. Journ. Med. Sci., April, 1873, p. 549.
* Ibid., July, 1873, p. 39.
1878.] Beane, Rectotomy in Stricture of the Rectum. 391
three) enemata daily are necessary, as were given in this case. At each
washing a sufficient number of injections should be made till the water
comes away comparatively clear ; one small enema can never answer, usu-
ally three or four in succession are required. The absence of continued
high temperature is worthy of remark. Suddenly developed and continued
high temperature should be a reliable sign of some complication, it may be
assumed from past observation.
I think the dilator, in my case, was used sooner than was necessary,
although not practically introduced till the ninth day after the operation,
so small was the circumference given it the seventh day. Were I again
to operate I would not introduce the bag sooner than the fourteenth day.
Until this time at least, the parts are inflamed and swollen, thorough
repair by granulation has only commenced, no good can be accomplished
by pressure before this period. Since no contraction can take place till
after there is well-established granulation and cicatrization, there is no
need for the instrument ; and why meddle with the parts prematurely ?
A slight curve should be given the bag, to correspond to the sacral curve ;
the point kept against the left side of the gut, to avoid either wound, and
pushed at least an inch above the former stricture. The required amount
of water is to be thrown in gradually, never rapidly. When no ether is
administered, ten, at most fifteen, minutes is long enough for its retention
after proper circumference has been obtained, as nothing is to be gained
by longer retention ; under ether, half an hour at longest may be allowed.
Anything which tends to irritate is pernicious ; short-continued pressure
gives increased circulation and tone to the parts, whereby the resorption
of the old exudation takes place ; but if that pressure be continued too
long (one or two hours) the reaction is excessive, instead of increased
vitality there come congestion and irritation in the widest sense. The best
authorities on urethral stricture warn against aught but the shortest reten-
tion of dilating instruments, except in " continuous dilatation," where the
contraction is made to yield by a process of ulceration ; but that the ten-
dency to recontraction is ahvays greater than after simple dilatation is
unanimously conceded. Unlike the period of retention, the interval be-
tween the introductions should be long. Of course it is impossible to spe-
cify time, frequent digital examination is the best guide ; on the appear-
ance of increasing hardness or recontraction, dilate.
My patient not only complained of pressure and bearing down, but " it
seems as though it is about to tear my insides into pieces" when the dilator
was in situ. Its retention always gave rise to considerable suffering,
though partly from acquired " nervousness." The non-administration of
ether during dilatation is an immense advantage ; the patient's feeling being
a reliable guide to the amount of dilatation as well as length of retention.
Dilatation to the point of maximum tolerance, retention till the pressure
becomes absolutely unbearable, will safely and satisfactorily lead the surgeon.
392 Beane, Eectotomy in Stricture of the Rectum. [April
When the patient is hysterical or unreasonably " nervous" ether becomes
a necessity ; but whenever possible it should be avoided.
Attention is now invited to some of the sequelae of the operation. The
neuro-muscular peristaltic power is greatly impaired from distension of the
gut above the stricture, incomplete emptying, and long-continued and fre-
quent straining ; consequently we could not expect immediate return to nor-
mal power after the removal of the obstruction, and the fact stands that two
or three stools daily are necessary for the complete evacuation of the large
intestine. This, however, does not in the least detract from the merits of
the operation, inasmuch as time and peristaltic tonics (strychnia, atropia.
physostigma) can, to a great degree, remedy this. The importance ot
daily evacuation of the bowel, and the injurious effects of constipation,
cannot be overrated. Cathartics should be shunned ; only aperient peri-
staltics should be used.
The muco-purulent discharge, lasting about five months, was due to the
slow return of the mucous membrane, in and about the cicatrices and old
induration, to normal function. The subsequent watery (mixed with
mucus and feculent matter) discharge was due to the lack of vaso-motor
tone. Had mine been a prudent, self-interested patient, undoubtedly this
long-continued discharge might have been removed in a few months by
care and vaso-motor tonics. In my case " bearing-down" ceased with the
operation, and did not return till fourteen months after the previous intro-
duction of the dilator, then only to a slight degree ! Great improvement
in the general health followed the operation in spite of two poisons, alcohol
and syphilis. The decided superiority of starch iodide over the potassic
salt is worthy of note. Had it been taken regularly, proper attention
to health been observed after August, 1876 (when nearly every secundo-
tertiary manifestation had disappeared), and alcohol been eschewed, I
doubt not the long history of sequela? might have been absent. In April,
1876, when the general health was excellent and the rectal function, in
the one essential respect, was normal, the systemic poison began to show
greater activity and continued to assert itself, in one way or another, there-
after. Some might incline to the post hoc, propter hoc reasoning ; with
such I disagree. Why ? The eruption was present when first I saw her ;
mercurials improved it for awhile (see July 23d. 1875) ; the constitutional
poison steadily acted (aided by alcohol) in spite of country air, etc., local-
izing itself, however, in the rectum, in the face of specific treatment (see
Sept. 10th, 1875, till Dec. 1875) ; bougies, however, lessened its local
activity, till the operation, by relieving local irritation, and the withdrawal
of alcohol, held it in abeyance for months ; finally it broke forth anew, but
in a more superficial form.
This is simply an exemplification of the course of syphilis in many
cases ; the suppression of manifestations being due to either specific treat-
ment or improved general health. The case under consideration, relieved
1878.] Beane, Rectotomy in Stricture of the Rectum.
393
of a prolonged irritation and drain upon the system, I think, comes under
the second category. Although the blood-poison began its attack in April,
187C, and continued thereafter, the bowel affection was improving all the
while and continued improved for 'many months, despite neglect, abuse,
and two poisons! Unfortunately, the precise time of commencing recon-
traction, and its course, could not be physically ascertained ; its inception
could not have been earlier than a few months subsequent to May, 1876,
since in fifteen months (May, 1876, to Aug. 1877) the recontraction had
only amounted to one-half of the original calibre. A different result could,
I think, have been recorded had my patient been tractable and far-sighted,
submitting to the use of the dilator at intervals varying to the necessity
for preserving the full calibre of the gut. It would be a great triumph of
surgery could the full calibre be preserved by the use of the water-bag
once a month. I doubt not the intervals might be prolonged to two
months, perhaps three, under such circumstances as might have obtained,
judging from the condition presented in May, 1876, after a lapse of sixty-
three days.
More or less precise directions for differential diagnosis of various forms
of rectal constriction exist ; but men of great experience and acumen mis-
take the benign for the cancerous affection, proving how difficult it is in
some cases to distinguish one from the other. Undoubtedly the cancerous
element is present f rom the beginning^ if at all, and as this operation would
seem to promise equal prolongation of life, as lumbar colotomy in cer-
tain of these cases, we should have some guiding landmarks in their selec-
tion. No precedent exists for believing the removal of irritation in this
locality (rectum) can dissipate disease of a malignant character, all cases
of cancer having died a short time following lumbar colotomy. The selec-
tion of proper cases in general has as much bearing upon success as the
operation itself ; the following indications may be worthy of attention.
Antero-posterior linear rectotomy is indicated in cases of simple cica-
tricial or fibrous, syphilitic or chancroidal contraction, of calibre No. 4,
English rectal bougie, or less, located at or above two, not more than four,
inches from anus, ulceration or no, occurring in females.
When near or involving the anus, the posterior incision should be car-
ried from the highest point of the stricture through all the tissues below,
as in fistula in ano.
Simple posterior linear rectotomy is indicated when the above conditions
obtain in males, and in cancerous strictures, of whatever calibre, when the
pain, effects on general health or impaired defecation (diarrhoea or consti-
ation), warrant it, non-ulcerative or slightly so, at or below four inches
from anus, tissues above not becoming involved.
In cancerous stricture this operation is far superior to lumbar colotomy,
inasmuch as it coequally prolongs life without the inconveniences and
loathsomeness of an artificial anus, and the danger is no greater. Where
No. CL — April 1878. 26
394
Dulles, Supra-pubic Lithotomy.
[April
there is cancer with extensive ulceration, breaking down of tissues and
spreading disease, lumbar colotomy is the only resort. Rectotomy, in
either form, should be the resort in all cases, with the one exception, how-
ever slight the contraction. Internal urethrotomy is eminently successful
in "penile" strictures, bougies are simply an annoyance. The present
well-established rule, " cut all penile strictures," is equally applicable to
rectal constrictions of whatever calibre.
There shall probably come a time when a just appreciation of the merits
of this operation will lead the surgeon to perform it much earlier in the
course of the disease than has heretofore been done. Like ovariotomy
and gastro-hysterotomy, it will not be accepted as the dernier ressort, but
undertaken before the system has broken down under untold pain and
suffering.
225 West 10th Street, New York, January 22d, 1878.
Article IX.
Supra-Pubic Lithotomy. By C. W. Dulles, M.D., of Philadelphia.
With a Table of Operations by this Method during the last Ten
Years, and a Report of a Case by Geo. W. Rachel, M.D., of New
York.
More than a hundred and fifty years ago, Cheselden, convinced by the
demonstration of John Douglas that it was practicable to remove vesical
calculi by incision above the pubes, adopted this method, and carried it
out so happily that he lost only one of ten patients, and that one solely
from his own extreme indiscretion. His great success, however, excited
against him the jealousy and bitter animosity of Douglas, who persecuted
him on account of this operation, accusing him of stealing credit which
belonged rightly to another. At the same time, so rude was the surgery
of that day, that other men, attempting this method, cut the peritoneum,
and actually burst the bladder when they meant simply to distend it ;
which occurrences led Cheselden to leave off what he had so well begun,
and go in search of some other wTay. This resulted in his applying his
great skill to the perfecting of the method of Rau, converting it into that
so universally known and practised as Cheselden's, or the lateral opera-
tion. Yet, for all this, he was not so much influenced by the sudden tide
of alarm which had risen from the accidents alluded to, as to be blinded
to the many advantages of the high or supra-pubic operation. In giving
his reasons for leaving it, he says :* " Though this operation came into
1 William Cheselden : The Anatomy of the Human Body. 8vo. London, 1740.
5th ed.
1878.]
Dulles, Supra-pubic Lithotomy.
895
universal discredit, I must declare it my opinion, that it is much better
than the old way, to which they all returned, except myself, who would
not have left the high operation, but for the hopes I had of a better, being-
well assured that it might hereafter be practised with greater success."
That the time he anticipated is now at hand seems to be indicated by
the growing interest which is being taken in supra-pubic lithotomy, the
modification of former judgments in the presence of larger information,
the willingness to make due allowance for accidents which have been utterly
foreign to the method, and the recognition of the fact that it presents ad-
vantages which cannot be fully appreciated until they are tested on rea-
sonably favourable subjects, and not confined almost exclusively to the most
hopeless.
Some evidence of this may, I think, be gathered from the history of
and the remarks suggested by the following case, which was kindly fur-
nished me by Dr. Geo. W. Rachel, of New York, in response to a request
for such information contained in previous articles upon this subject, and
which I would now renew : —
Henry W., aged 4 years, of average development, was first examined
by Dr. Rachel, Nov. 21st, 1875. He had been suffering from symptoms
of stone in the bladder for a year and a half. His general condition was
very poor ; temperature, 101^° (Fahr.) ; his pulse, 100, and very feeble ;
he had chronic bronchitis ; his urine contained blood, pus, and epithelium
from the pelvis of the kidneys and the bladder, as well as -eight or ten per
cent, of albumen. His hands and feet had been for a few weeks a little
swelled.
Having discovered a calculus, apparently of considerable size, it was de-
termined to attempt to relieve the child by lithotomy. This seemed to
offer the only chance of prolonging his life, though undertaken with a full
appreciation of the fact that the prospect of a successful issue was very
slight. Owing to the consideration of the dangers of perineal lithotomy, and
the advantages of the supra-pubic method, as well as the favourable opinion
of the latter expressed by a number of German surgeons, Dr. Rachel
selected this, and, with the assistance of Drs. Lilienthal and Guden, car-
ried it out on Dec. 7th, 1875.
Following the recommendation of Roser, instead of an injection, he
availed himself of the urine accumulated during a number of hours im-
mediately preceding the operation, and which distended the bladder up
to the umbilicus. An incision was made from half an inch below the
umbilicus to the level of the symphysis pubis, exposing the linea alba,
which was divided upon a director to an extent of about three inches.
The tendons of the recti and the pyramidalis muscle were nicked to a
depth of half an inch on each side, and hooked up with the fingers. The
bladder was now easily cleaned of its fat, and its bluish-gray surface ex-
posed, without meeting the peritoneum at all. It was then steadied with
the second and third fingers of the left hand, and incised quickly from
above downward. Instantly the index of the left hand followed the knife
into the opening, a little urine escaped, while the stone was whirled up by
the current, and caught upon the finger of the operator. The incision
being too small to pass both the finger and the stone,. it was enlarged some-
396
Dulles, Supra-pubic Lithotomy.
[April
what by cutting directly upon the latter, which then slipped easily out ;
the ease and rapidity of the whole proceeding being a source of astonish-
ment and delight to Dr. Rachel and his assistants. The bleeding en-
countered was insignificant.
Careful search disclosing no other calculi, the bladder was held up by
the edges of wound, and its contents drawn off per urethram with a
catheter. In the whole operation not more than one ounce of urine
escaped through the wound. This was now cleaned with sponges soaked
in a one per cent, solution of carbolic acid, and closed — excepting about a
third of an inch at the lower end — with five silver wire sutures, which
were made to include both the bladder and abdominal walls. The whole
was covered with a piece of lint, soaked in a five per cent, solution of car-
bolic acid.
The same evening the boy's temperature rose to 102j°,and his pulse t<»
114. He complained of much pain, and was given opium, The morn-
ing after the operation his temperature was 103^°, his pulse 124: by
evening the former was 105 J°, the latter 150. He was placed in a semi-
recumbent position to be changed to the side occasionally, and ordered to
be put in a warm bath twice daily. The second morning his temperature
was 102^°, his pulse 140 ; in the evening they were 103° and 120. The
third morning they were 102^° and 1 1 G, and in the evening 1014° and 108.
During all this time his urine had flowed almost entirely through the
urethra ; he ate well, was cheerful, and seemed to be getting along nicely.
Yet on examination of this last clay's urine, it was found, after filtering,
to contain twenty-five per cent, of albumen.
The fourth morning his temperature was 100^°, his pulse down to 90.
All the sutures but the lowest were now removed. During the day the
flow of urine per urethram ceased entirely, and an injection of the bladder
with warm Avater was made through a catheter. This " removed some
plugs of mucus and secretion from the wound." In the evening his tem-
perature was up again to 103°, and his pulse 128. Later in the night he
had much fever, with coughing and some dyspnoea. There was dulness
over and below the right scapula, both respiratory sounds were very much
roughened, and dry and moist rales abundant, the latter more especiallv
on the left side. The wound now for the first time looked badly, and
from this he grew steadily worse, becoming delirious, and never regain-
ing consciousness. The next morning his temperature was 1021° : his
pulse, 120 ; his respirations, 42. The last suture was now removed. The
wound was slightly reddened and gaped. In the evening his temperature
was 103^° ; his pulse, 130 ; his respirations, 53. At 11 P. M., he vomited
what his parents called dark, bloody matters. Meteorismus now set in.
with fetid diarrhoea! discharges. The next day — the sixth after the ope-
ration— his morning temperature was 105-J-0, his pulse 150, his respira-
tions irregular; during the day he vomited a great deal of yellowish and
greenish mucus ; " his pneumonia speedily grew into an oedema pulmo-
num." His evening temperature was 104f c, with irregular respiration
and an uncountable pulse. At 11 o'clock the following morning, just seven
days after the operation, he died.
No autopsy was permitted; but Dr. Rachel and Dr. Guden, on inspec-
tion, judged there was " little ground for suspicion of infiltration of urine.
The wound, however, was gaping much wider than three days before, and
looked very unhealthy." Death, Dr. R. thinks, was " primarily due to
pneumonia; but the vomiting, the meteorismus, the fetid discharges, and
1878.]
Dulles, Supra-pubic Lithotomy.
397
the low, muttering delirium point to a process of blood-poisoning which,
in the absence of an autopsy, remains somewhat of a mystery."
Subsequent examination showed the calculus to consist of a nucleus of
urates, surrounded with alternating layers of oxalates, carbonates, and
phosphates. Its weight was 5u? arid i*s diameters one and one-quarter
inch, one inch, and three-quarters of an inch.
The issue of this interesting case cannot surprise us if we bear in mind
the condition in which the little patient was before the operation. The
evidences of advanced renal disease, complicated with pulmonary trouble,
were certainly sufficient to justify the hesitation to institute surgical inter-
ference and the gloomy prognosis of Dr. Rachel. Yet the case deserves
more than a passing notice ; because in such unusual operations each one
is likely to be taken as a representative of the entire class. And no mat-
ter how its advocates may deprecate this, it will avail nothing unless they
specify the matters to which they take exception. For this reason I feel
it proper to . make some comments in regard to this operation, founded
upon investigations which have now extended over four years, and em-
braced careful study of above five hundred cases.
The first of these comments relates to the means adopted to raise the
bladder out of the pelvis. As I have already stated (Am. Journal Med.
Sciences, July, 1877, p. 119), it is a mistake to suppose the bladder must
be distended. This is clearly indicated by the history of the method, and
I have repeatedly demonstrated on the cadaver the ease with which the
entire operation can be done .with no instruments but a knife, a tenaculum,
and a catheter. A practical illustration of this was a case, reported to me
by Dr. Thomas W. Deering, and published in the Med. and Surg. Reporter
for April 29, 1876, in which he removed two calculi by the supra-pubic
operation, having no assistant, and no instruments save those in an ordi-
nary pocket-case.
Nevertheless, I believe, when it can be done, it is better to have the
bladder distended, but not with urine. For it must be remembered that,
though fresh, healthy urine is an innocuous fluid, that which is found in
bladders containing calculi is not healthy ; and to have it come pouring
over the freshly-cut surfaces may introduce a needless element of danger.
I am aware some German authorities admit the propriety of allowing the
urine to accumulate and distend the bladder, in the manner practised by
Dr. Rachel. Yet it seems to me better, in an operation like lithotomy,
where so much may depend upon apparently minor details, and which is
usually done on patients already in very poor condition, to observe every
reasonable precaution, and eliminate every source of danger we can. For
this reason I think the bladder should, before operating, be emptied of any
accumulated urine, thoroughly washed out, and then carefully distended
with some fluid.
The manner of washing out the bladder is important. Experience and
398
Dulles, Supra-pubic Lithotomy.
[April
observation in the treatment of inflammations of the bladder have taughl
me it was a mistake, in my first paper on this subject,1 to speak of using
a double catheter. The proper way is to inject — with hydrostatic pres-
sure if convenient — a small quantity of fluid through a simple catheter,
and when the bladder resists pretty strongly let it flow away. Repeating
this a number of times the whole of the interior of the viscus may be
thoroughly cleansed. The fluid used may well contain some antiseptic,
carbolic acid in one per cent, solution being perhaps the best,2 and should
invariably be of the temperature of the interior of the body, otherwise
spasm may be excited, and the procedure made very difficult or impossible.
When the bladder has been thus washed out, the same solution can be used
to furnish distension for the operation ; after which we may be pretty sure
that the fluid which comes first into contact with the wound will be quite
harmless.
There is no step in an operation of supra-pubic lithotomy of greater im-
portance than the precaution of securing the bladder with a tenaculum
before incising it. This was omitted in the case before us. Fortunately
the movement of the calculus prevented the escape of the contained fluid,
or the bladder would have collapsed, causing serious embarrassment in
the subsequent steps. This actually occurred in a case recently reported
to me.
In regard to the treatment of the wound, there has been some difference
of practice among those who have done this operation in the past twenty-
five years. Most surgeons have left it pretty much to itself. Giinther,
an ardent advocate for the method, who collated and published in 1851
the statistics of 260 cases,3 and who did eight operations without losing a
single patient, simply applied cold, wet compresses, after putting a stitch
in the upper part of the abdominal wound, if it was long. It is indubitable
that very good results may be thus obtained, yet the most brilliant have
been secured by carefully closing the wound in the bladder with sutures.
This has been done by Lotzbeck and Bruns,4 with the result of union by
first intention. It has also been done wTith complete success in this
country : several times by Bell ;5 once by Brady,6 with healing of the
wound in eight days ; once by Deering,7 writh complete recovery in four-
teen days ; and once by Starr,8 with recovery in sixteen days.9 These re-
1 Am. Journ. Med. Sci., July, 1875.
2 Vide Schiiller ; Ueber die Localbehandlung des chronischen Blasenkatarrhs. Ber-
lin, 1877.
2 Giinther, Der hohe Steinschnitt, Leipzig, 1851.
4 Pitha und Billroth, Handbuch der Chirurgie, Bd. III., 2te Abth., s. 110.
* Western Journ. of Med., Nov. 1867 ; and letters to the Author.
6 Detroit Rev. of Med. and Pharmacy, Sept. 1869.
* Med. and Surg. Reporter, April 29, 1876.
8 Am. Journ. of Med. Sci., July, 1877.
s In some of these cases the abdominal wound was also closed.
1878.]
Dulles, Supra-pubic Lithotomy.
399
suits indicate, I think, that sewing up the bladder is of decided advantage.
It should be done by itself, and not in common with the abdominal walls.
The few cases where the latter plan has been adopted, with which I am
familiar, confirm me in this opinion. The external wound may be partly
closed; leaving an open space below for the ends of the bladder sutures,
for drainage and for observation.
The subsequent treatment is quite simple. A light absorbent dressing
should be applied, the strictest cleanliness observed, and the urine drawn
off from the bladder at short intervals until the wound is consolidated. A
catheter should by no means be left in the urethra. The literature of the
operation leaves this beyond doubt. The making of a counter incision
through the perineum, such as was used by Cosme and Souberbielle, is
utterly unwarranted by experience. Both these have been recommended,
and practised, too, in former times, from a dread of urinary infiltration and
peritonitis. Now, however, these dangers have been shown to be greatly
over-rated and such proceedings, with a view to avoid them, to be worse
than useless. In regard to this, Podrazki, who furnishes the article on
Diseases of the Penis and Bladder, in Pitha and Billroth's Handbuch der
Cliirurgie, and who shows great familiarity with this subject, after ex-
pressing the same opinion as that just stated, says : " From all this, it is
seen that, in general, the pretended danger of urinary infiltration can of
itself alone furnish no contraindication at all to supra-pubic lithotomy."
And again : " Though, further, it was insisted that in supra-public litho-
tomy the peritoneum was more imperilled than in any other method, yet
this danger also was unreasonably exaggerated."1
Returning to our case, we must notice the injection of the bladder on
the fourth day — for the purpose of clearing the urethra — to the extent of
forcing " some plugs of mucus and secretion from the wound." This is
not without precedent ; but, unless I am mistaken, it has been practised
mainly by Gihither, who, it must be remembered, did not close either
bladder or abdominal wound. I do not think his example should be fol-
lowed where either of these have been sewed up. In such cases, if the
desired end could be attained without the employment of so great force, it
would probably be safer for the patient.
Finally, I would call attention to the fact that Dr. Rachel writes me,
that, notwithstanding the fatal termination of this case, it has strengthened
his conviction that supra-pubic lithotomy is far preferable to that by peri-
neal section. He quotes Bardeleben, who says (Lehrbuck der Chfrurgie,
Bd. IV. s. 215) : " In children, up to the age of puberty, the supra-pubic
method must be considered the very best for small as well as for large
stones."
Podrazki says,2 in his comparison of the various methods of lithotomy : —
1 Op. cit., Bd. III., 2te Abth., seite 111.
2 Op. cit., seite 126.
400 Dulles, Supra-pubic Lithotomy. [April
"All the objections which, in earlier times, it was believed could be raised
against this method, experience has fully refuted . ' '
Again : —
"Too great stress cannot be laid upon the importance of supra-pubic lithotomy
for children. ' '
And, further : — 1
"The mortality is certainly as yet greater after supra-pubic than after lateral
lithotomy, which, however, may depend solely upon the fact that hitherto only the
specially unfavourable cases have been subjected to supra-pubic lithotomy ; and
it is not to be doubted that, with the more frequent employment of this method,
and the greater technical dexterity thereby attained, together with a rational
selection of cases, the results will also become much more favourable."
Such is the expectation of every one who has had time and inclination
to fully investigate the subject. That it is being now fulfilled may be seen
from the following table, extracted from my statistics, which includes all
the operations by supra-pubic lithotomy practised during the past ten years,
of which I am informed : — 2
Suprapubic Operations during the last
Ten. Years.
a
a
s
o
o 'J2
s
6
"eS
tfl ft
SZ5
W
^_
<
"3
Merbier
1S67
30
2
Bell*
1867
4s
3
Bell
1S72
3
4
Boll
1S7.5
2
5
Bell
1875
32L
6
Brnrfie*
1S6S
3.3
7
B> ady
1S68
42
8
Betz
1869
6
9
Betz
1S70
s
10
Deering
1S70
46
11
Watson
1871
56
12
Bock
1873
6
13
Bock
1S74
3
14
Bock
1S74
4)
15
Bailey
1874
— 3
16
Billroth
1S74
12
17
Langen-
1S75
11
bec c
18
Uncivil
1S73
4
19
Starr
1S76
35
20
Fletcher
1S76
2|
Description of
calculi.
511]., 5ujss.
grs. xvi.
grs. xcvi.
5ij.
Large bean size.
Walnut size.
Sijss.
Acorn size
Cherry size
2 S 5iv. grs. xx. )
( nv. grs. xiv. $
gviijss.
Sj.
grs. xxv.
grs. lvijss.
grs. liv.
A tumour, apple size
Date seed size.
5ij.
Sj-, Sj.
grs. lxviijss.
4 i (1 a v s
26 "
21 "
30 "
62 "
21 "
42 "
42 "
14 "
42 «
21 "
12 "
11 "
21 "
33 "
Eeference.
Gazette Hebdom., 1S59, p. 583.
Western .Tourn. of Med., Nov. 1867.
Memo rabi lien. Heilbronn, Mar 28,1574.
Indiana .Tourn. of Med., Au.r. 1875.
Am. Practitioner, Mar. 1876.
Letter from Dr. Brodie, Mayo, 1876.
Detroit Rev. Med. & Pharm. Sept. 1869.
Memorabilieu Heilbronu, Feb. 28,1S74.
Med. & Surg. Reporter, Apr. 29, 1S76.
Letter from Dr. Watson, Oct. 6,1874.
Dr. Bock, Sept. 10, 1874.
" " Dec. 8, 1874.
" " Jan. 3 ), 1S78.
" Dr. Bailey, May 28, 1875.
" Dr. Karl Schwaighofer
Nov. 3, 1874.
Arch. f. Kl. Chir. Bd. xxi. Sup. Heft,
S. 210.
This article.
Am. Journ. Med. Sciences, July, 1877.
Letter from Dr. Fletcher, Jan. 3J,1S7S.
Recovered 18
Died 2
Total . 20
Average time of recovery, 29 days. Death ratio, 1 : 10
1 Op. cit., seite 127.
2 There are omitted from this table two operations which were done immediately-
after failure of lateral lithotomy.
3 The names in italics are of American surgeons.
4 Brodie's patient was a female.
1878.J
Dulles, Supra-pubic Lithotomy.
401
A superficial examination of this table would lead us to consider the
cases as a pretty fair representation of the general run of lithotomy patients.
That they are not too favourable for comparison will be seen when we note
the general relation of the size of the* calculi to the ages, as well as the fact
that there were in five out of the twenty cases stones weighing over an
ounce, in one the weight was 2^ ounces, in one nearly 3^ ounces, and in
one as great as 8^ ounces. This calculus was, as Mr. Patrick Herron
Watson writes me, as large as the closed fist. He says, further, " I ope-
rated in the first instance by the ordinary lateral operation, but, finding
the calculus unmovable, I at once cut above the pubes. Even then there
was much difficulty in effecting its extraction, as the coats of the bladder
clung to the stone, and ultimately it was only by pushing back the vesical
coats off the stone, while the forceps communicated a twisting or spiral
movement to it, that the stone was removed. Six weeks elapsed before
the wound was quite healed. The perineal wound healed first." Thus
one of the cases is seen to have been of the gravest possible character, and
the operation complicated with an unsuccessful attempt by the lateral
method. Billroth's operation was done to remove a myoma, the size of
an apple, and was complicated by opening the bladder through the peri-
neum.
Yet with all this there were only two fatal cases among the whole
twenty. One of these, being described in this article, needs no further
comment. In regard to the other, the operator, wTith rare and honourable
candor, authorizes publication of the following epitome : " Child under
chloroform ; bladder distended with water ; incision an inch and a half to
two inches long; stone removed speedily; peritoneum cut by carelessness,
and the wound improperly dressed — result death/'
In concluding, I desire once more to urge upon the profession the care-
ful consideration of this method of lithotomy, which recommends itself so
highly on theoretical and, I believe, also on practical grounds. It is not
necessary here to speak of its simplicity, the ease with which it may be
carried out, the direct and unembarrassed route to the bladder it offers,
the facility of finding and removing a calculus. These will suggest them-
selves to every anatomist, and have been already quite fully stated in the
number of this Journal for July, 1875, to which I would refer anyone
who is interested in the subject. These advantages are in striking con-
trast to the complications and hazards attaching inseparably to lateral
lithotomy, which may be found stated in every work on surgery. The
statistical comparison, as usually made, does not, it is true, make such a
good show as one would suppose a priori ; but the deliberate judgment
of surgeons must admit that such a comparison is not to be depended on
in determining the merits or possibilities of the method, without giving due
weight to those disadvantages under which it has laboured. Investigation
shows that these disadvantages, which are more than sufficient to account
402
Forbes, Nitrite of Amyl in Hydrophobia.
[April
for the difference between what the results have been and what they should
be, are entirely extrinsic and in no way pertain to the method as such.
That they disappear in the presence of wider information and higher sur-
gical skill, I believe to be indicated by the table above, which shows that
in the past ten years the results of supra-pubic lithotomy have been as
good as those claimed for any other method.
4041 Locust Street, Philadelphia.
Article X.
The Relief obtained by the Use of Nitrite of Amyl in Two Cases
of Hydrophobia. By W. S. Forbes, M.D., Senior Surgeon to the Epis-
copal Hospital, Philadelphia.
In a paper1 read before the College of Physicians some time since, on
the use of nitrite of amyl in tetanus, I recommended its use in hydrophobia.
Since then it has been used in two cases, in one of which I was called
in consultation. The other occurred in the practice of my friend Doctor
Solliday, of Tamaqua, who very kindly furnished me with the notes In-
made at the time he treated the case. In both instances the relief on the
inhalation of the amyl was very great and exceedingly comforting to the
patient.
In each case the first applications of the amyl relieved the patient of that
dreadful feeling of impending dissolution wmich is so striking a feature in
this malady. It calmed them and enabled them to swallow botli water and
food to satiety. In neither case did the amyl appear to stay the advance
of death. In both cases, however, the sufferings, preceding the last parox-
ysm, wrere relieved. The pulse fell, the sense of choking vanished, the
breathing became regular and natural, the function of swallowing perfectly
restored, and sleep obtained. In both cases death took place while the pa-
tient was in spasms.
The first case was Doctor Solliday's. The second case I saw myself.
Case I — Kate H., aged seventeen years, was bitten by a Spitz dog on
the 26th of November, 1877, on the the lower lip. The wound was very
slight, and healed quickly. On the 20th of December (three weeks and
three days after the accident had happened), in the evening, she called
at my office in a very excited state of mind, which she attributed to
a fright she had some few hours before, and complained of a choking
sensation coming on at intervals. Attributing her symptoms to hysteria
some antispasmodic medicine was prescribed. Early the following morn-
1 Transactions of the College of Physicians of Philadelphia, third series, vol. i. Case
of Acute Tetanus successfully treated by the Inhalation of the Nitrite of Amyl.
Read April 7, 1875, by W. S. Forbes, M.D.
1878.] Forbes, Nitrite of Amyl in Hydrophobia.
403
ing I was summoned to her home and found her in a spasm, and upon
inquiry then learned for the first time that she had been bitten by a Spitz
dog.
The case was one evidently of well-developed rabies in all its bearings.
The spasms came on every fifteen minutes.
There was total inability to use fluids, the very mention of which would
produce a spasm. A quarter of a grain of morphia was given hypodermi-
cally. I saw her again three hours afterwards. There was no change.
Half a grain of morphia was then given her hypodermically, but without
the least noticeable effect. On the evening of the 21st, I gave her twenty-
four drops of the nitrite of amyl by inhalation. She now complained of
numbness in her extremities, and remarked that if the room was quiet she
could sleep. At this moment I gave her a glass of water, which she swal-
lowed without trouble. In fifteen minutes she Avas in a quiet sleep, which
continued for four and a half hours. She was awakened by a violent storm
of rain which made a great noise on the roof and shed of the house in
which the patient lived. The spasms immediately began and were more
violent than at any prior time, and continued until death took place late in
the afternoon of the 21st. No post-mortem examination was permitted.
Case II Michael C, thirty years of age, a bartender, was bitten on
the 1st January, 1877, on the back of his left ring finger by a terrier dog
which was suffering from rabies. On the 27th of March following, I was
called to visit him in consultation by Dr. William Carroll of this city. Dr.
Whitmer was likewise called in.
The patient stated that on the 20th of March the scar assumed a red,
swollen look, and that an eruption appeared on the following day, the 21st.
The eruption disappeared on the 26th, and in the afternoon of that day he
felt stiff back of his neck and as if he had taken cold.
Late the next day Dr. Carroll was consulted, and prescribed for him, and
when the patient attempted to swallow the medicine he found that he could
not possibly do so. Doctor Carroll was immediately sent for, and at once
told his friends that the man had hydrophobia. I saw the patient at mid-
night in consultation. I found his pulse rapid, 140, quick and small. His
skin leaky and cool, and his countenance anxious, and his whole expres-
sion wild.
On.talking to him a few minutes, I asked him if he had taken any nour-
ishment; he said not since breakfast the day before. On asking him if he
would like to take some milk, he said emphatically he would like it very
much, but that he could not possibly swallow it, the very suggestion of it
almost prevented him from breathing. At this moment, while talking, he
sat up in bed, and his respiration became quick, and he became very much
excited. The milk was brought, and he made violent efforts to control
himself ; he attempted to seize the glass, but it was only to grasp at it ; he
could not possibly take hold of it, and entreated us in a wild convulsive
manner to take it away.
I then immediately advised that we should give him twenty-five drops
of the nitrite of amyl by inhalation, which was done at once. By the time
the evaporation of the amyl had taken place from the towel on which it
had been given, the man said " What is it that you have given me ? it
is running all around in my head." When two or three minutes had
elapsed his pulse was found to be 88, and his respiration quite natural, and
he appeared to be quite calm. I then asked him if he thought he could
take some milk ; he said he thought he could ; the milk was brought, and
404
King, Suffering from Deprivation of Water.
[April
he swallowed a pint with the greatest ease. He said he would take some
more ; that he had had nothing since breakfast the day before. Half a pint
more of milk was then given to him with two ounces of brandy, and when he
had swallowed it he asked one of the bystanders to give him a drink of water.
The water pitcher was brought, and I poured out a glass full before him ;
and taking the glass as composedly as any one would, lie drank off the
whole of the water with the greatest comfort, and, he holding the glass out,
I filled it again ; after drinking nearly all of the water, he exclaimed, " Oh
but that is good." I sat with him nearly two hours longer, during which
time he wras perfectly composed and got some sleep; then his pulse became
more rapid and his breathing more frequent, and he asked for the amyl
again, and- 1 again administered about half a teaspoonful. Before doing
so, howrever, I asked him if he would take a little brandy and water, when
he replied, no, not until after breathing "that stuff," as he called the amyl.
The second application of the amyl had the same happy effect as on the
first occasion ; his pulse fell, his respiration became more calm, and he said
then he would drink some milk, of which he took about half a pint, when I
told him he had better take one or two eggs. Three raw eggs were then
mixed up with half an ounce of brandy, and he swallowed them very
readily and with great comfort, lie then fell asleep, and I left him.
I returned the next morning at 9 o'clock, and asked Doctor John Ash-
hurst to see him in consultation with Dr. Carroll and myself. We
found our patient had slept some, but for an hour or more had been very
much excited.
He could not have the glass of water brought near him ; it was tried, and
on its approach he became very much excited, and shook convulsively.
Nearly a teaspoonful of the nitrite of amyl was now administered, and he
again became quite calm and drank nearly half a pint of water, and soon
after took some milk and eggs. On consultation we gave him half a grain
of morphia hypodermically, and ordered both the morphia and the amyl
to be repeated as occasion required.
At noon lie became excited, when three-quarters of a grain of morphia
injected under the skin again quieted him.
At three o'clock, however, he again became very much excited, and, on
attempting to give him the amyl, he exclaimed that he was choking, and
immediately went into a convulsion which ended in death.
No post-mortem examination was permitted.
Article XI.
Brief Account of the Sufferings of a Detachment of United
States Cavalry, from Deprivation of Water, during a period of
eighty-six hours, wthile Scouting on the "Llano Estacado" or
"Staked Plains," Texas. By J. H. King, M.D., Captain and Assistant
Surgeon U. S. A.
It should be stated that the following report is not based upon personal
observation. The writer was one of the relieving party sent in quest of
the lost men, and shortly after meeting them noted down the substance of
1878.] King, Suffering from Deprivation of Water.
405
this paper, which he gleaned while the events were still vividly impressed
on their memories. It is feared that some of the details may, at first sight,
appear scarcely worthy of notice ; but any particulars concerning human
beings deprived of water for such n long period, and under such circum-
stances, apart from bearing in a measure upon physiological science, are
not totally devoid of interest.
On the evening of August 4th, 1877, two non-commissioned officers and
one private belonging to company "A," tenth cavalry, came into Fort
Concho, Texas, reporting that Capt. Nolan and Lieut. Cooper, with twenty-
six soldiers, while in pursuit of marauding Indians, had wandered amongst
the sand-hills on the Staked Plains ; that no water could be found, and
that, when last seen, the whole command was exhausted and dying of
thirst.
A relieving party, to which the writer was attached, was organized at
once, and left immediately in search of the missing men. After a rapid march
of sixty-two hours we reached Capt. Nolan's supply camp, situated seven
miles northeast of the Muchakoway Mountain and 140 miles from Concho,
where we learned that Capt. Nolan, Lieut. Cooper, and all the men except
four had just come in safely one hour previously.
As the lost men advanced towards us, we remarked their changed appear-
ance since we had last seen them, a few weeks before ; their aged and care-
worn faces portrayed the hardships they had undergone, while additional
gray locks and other indications of sufferings were visible. The following
is the painful history which they narrated.
Capt. Nolan, Lieut. C. L. Cooper, and forty troopers of Co. A, 10th
Cav., with eight pack -mules, had for some days been scouting in the
region of " Double Lakes" and " Cedar Lake," looking for Indians. On
the 26th of July, 1877, a rumour was brought into camp at u Double
Lakes" that a band of hostile Indians had recently been seen passing
" Dry Lake." Capt. Nolan forthwith prepared to follow them, and broke
up camp at 1 P. M., July 26th.
The Indian trail was struck west of Dry Lake, and pursued until dark,
being then no longer discernible. The guide, in his anxiety to keep the
Indian trail, had neglected his landmarks, and was unable to find water
when the halt was sounded. The party were compelled, therefore, to
make a dry camp and so pass the night. On leaving " Double Lake,"
each man's canteen had been filled, but in consequence of the intense heat
they were emptied in the early part of the march, and what little water
" Dry Lake" contained was so strongly alkaline that neither man nor beast
could drink it.
At dawn the trail was again taken up and followed perseveringly, not
only writh a view of capturing the Indians, but also with hopes that it
might conduct them to some lake or water-hole. Their course lay over
a gently undulating country; the soil dry, mostly of a reddish colour.
406
King, Suffering from Deprivation of "Water.
[April
covered with bunches of short grass, here and there a stunted mesquite-
bush ten or fifteen inches high, and occasional twigs of scrub-oak of similar
size. The heat was excessive — " coup de soleil" had prostrated two men,
and all were suffering severely from thirst.
Towards sunset the trail commenced to spread, breaking into a multi-
tude of ill-defined tracks, rendering further pursuit useless, and the chase
was given up. Men had been thrown out on the flanks all day to seek for
water, and for the same purpose the guide explored every valley and de-
pression within view. Matters wrere assuming a grave aspect ; many were
faint and exhausted; some fell from their saddles. The horses needed
water equally with their riders. After adopting all customary methods to
extricate his command from this critical position, Capt. Xolan finally
mounted the guide on his private horse, a tough animal, and ordered him
to traverse the country, ranging wherever he thought it possible to find
water. This guide was never seen afterwards. Capt. Nolan for a time
awaited his return, and then determined to fall back upon " Double Lakes,"
which were supposed to be 75 or 100 miles distant, where he felt confident
of obtaining water.
Another day was drawing to a close, and, as night came on, advantage
was taken of the cooler atmosphere, and every nerve was strained to reach
" Double Lakes."
The next day found them still marching onwards, and the mid-day tropi-
cal heat causing great suffering. The desire for water now became uncon-
trollable. The most loathsome fluid would now have been accepted to
moisten their swollen tongues and supply their inward craving. The sali-
vary and mucous secretions had long been absent ; their mouths and throats
were so parched that they could not swallow the government hard-bread :
after being masticated it accumulated between the teeth and in the palate,
from whence it had to be extracted with the fingers ; the same occurred with
mesquite-beans and whatever else they attempted to eat. The sensibility
of the lingual and buccal mucous membranes was so much impaired that
they could not perceive when anything was in their mouths. The condi-
tion of the "prima? vias" may in a degree be realized, when it is explained
that brown sugar would not dissolve in their mouths, and that it was im-
possible for them to swallow it. Vertigo and dimness of vision affected
all ; they had difficulty in speaking, voices weak and strange-sounding ;
and they were troubled with deafness, appearing stupid to each other,
questions having to be repeated several times before they could be under-
stood ; they were also very feeble and had a tottering gait. Many were
delirious. What, little sleep they were able to get was disturbed with ever-
recurring dreams of banquets, feasts, and similar scenes, in which they
were enjoying every kind of dainty food and delicious drink.
At this stage they would in all likelihood have perished had they not
resorted to the use of horse-blood. As the animals gave out they cut
1878. J King, Suffering from Deprivation of Water. 407
them open and drank their blood. The horses had been so long- deprived
of every kind of fluid that their blood was thick, and coagulated instantly
on exposure ; nevertheless, at the time it appeared more delicious than any-
thing they had ever tasted ; in fact, every one was so eager to obtain it that
discipline alone prevented them from struggling for more than the stinted
share allowable to each. The heart and other viscera were grasped and
sucked as if to secure even the semblance of moisture. At first they could
not swallow the clotted blood, but had to hold it in their mouths, moving
it to and fro between the teeth, until it became somewhat broken up, after
which they were enabled to force it down their parched throats. This
horse-blood quickly developed diarrhoea, passing through the bowels almost
as soon as taken. Their own urine, which was very scanty and deep
coloured, they drank thankfully, first sweetening it with sugar. The in-
clination to urinate was absent, and micturition performed with difficulty.
A few drank the horses' urine, although at times it was caught in cups
and given to the animals themselves. They became oppressed with dys-
pnoea, and a feeling of suffocation as though the sides of the trachea were
adhering, to relieve which they closed the lips and breathed through the
nose, prolonging the intervals between each inspiration as much as possi-
ble. Gazing on each other, their lips thus closed were observed to be
covered with a whitish, dry froth, and had a ghastly, pale, lifeless appear-
ance, as though they would never be opened again. Their fingers and
the palms of their hands looked shrivelled and pale ; some who had re-
moved their boots suffered from swollen feet and legs.
The situation was now desperate, and feelings akin to despair took
possession of them — suspicious ideas towards each other came over them.,
and they lost confidence in each other. They again saw the sun set, and
another night was spent on these untrodden wastes, without alleviatiqn of
their misery. Persistent wakefulness now aggravated their mental an-
guish, and in vain at every halt they lay down and tried to sleep.
Their deplorable condition continued to gradually grow worse, until 5
A.M., July 30th, 1877, when, providentially, part of the command suc-
ceeded in making "Double Lakes." At this time a number of men were
missing, some having been unable to keep up with the main column, while
others had strayed after water.
Both officers and men were almost helpless on reaching " Double
Lakes," and the wished-for water did not greatly benefit any of them
this day. Canteens of water were at once strapped to the horses, and two
or three men sent with them on the back trail to succor and help on the
stragglers.
Fortunately, the following morning, Capt. Lee, 10th Cavalry, with a
detachment of Youkoway scouts, touched at " Double Lakes" and ren-
dered most valuable assistance to Capt. Nolan's party, despatching his
408
King, Suffering from Deprivation of Water.
[April
scouts on all sides to hunt for men and horses, and furnishing rations and
some delicacies which the sufferers were in absolute need of.
The demands of their systems were so imperative that the inclination
to drink was irresistible ; it seemed impossible to refrain from pouring
down water, notwithstanding that their stomachs would not retain it. A>
they kept filling themselves with water, it was vomited up; the same
thing occurred when they endeavoured to eat dry food. "Warm coffee was
the only thing they had that revived them at all, until after Capt. Lee
met them.
Although water was imbibed again and again, even to repletion of the
stomach, it did not assuage their insatiable thirst, thus demonstrating that
the sense of thirst is, like the sense of hunger, located in the general sys-
tem, and that it could not be relieved until the remote tissues were sup-
plied. Moreover, the activity of this regenerating process was prevented
by the deficiency of water in the absorbent vessels themselves. The same
cause is competent to explain the overpowering dyspnoea, which threatened
the existence of these men ; for only moist membranes allow the free
passage of gases which must take place in respiration. The lungs of
these men were filled with the purest air, yet they appreciated an almost
overwhelming sense of suffocation. Another point worthy of our attention
is the loss these men must have sustained by integumentary and pulmonary
exhalations. The mean daily exhalation of watery vapour in expired air
Valentin estimates at 1| lbs. av., and the daily loss by cutaneous trans-
piration at about 2 lbs.; in the case before us the quantities were influ-
enced and increased by the conditions of temperature, exercise, etc.
The superior endurance of the mule over the horse was obviously
manifested on this scout. The horses' tongues were swollen, mouths and
systems generally affected much in the same manner as the men's ; they
could not chew or swallow grass; many gave out completely. On the other
hand, the mules, comparatively unfatigued, would crop the grass and graze
at every halt.
It is essential to remember that the sensations of thirst, to which these
cavalrymen almost succumbed, were intensified by the dry state of the
atmosphere ; they were toiling over arid plains and elevated plateaus in a
climate noted for its lack of moisture.
On August 1st, 1877, Capt. Nolan heard that fourteen of his followers
had managed to get all right as far as the Supply Camp. His total loss,
therefore, after this disastrous scout, only consisted of two men dead and
two missing, supposed to be dead. Capt. Nolan remained five or six days
at " Double Lakes" to recuperate, and then retraced his steps to the Sup-
ply Camp, arriving there on August 7th, 1877.
Fort Clark, Texas, Jan. 21st, 1878.
1878.] Althaus, Acute Anterior Myelitis in the Adult. 409
Article XII.
On Acute Anterior Myelitis in the Adult. By Julius Althaus,
M.D., M.R.C.P. Lond., Senior Physician to the Hospital for Epilepsy and
Paralysis, Regent's Park, London.
Amongst the different forms of myelitis which come under our care
clinically, that which is confined to the anterior cornua of the gray matter
presents several features of considerable interest, more especially if we
view it in connection with infantile paralysis, which, according to recent
pathological researches, appears to be, to all intents and purposes, the same
disease. Before entering into the pathology and treatment of the affection,
I will as briefly as possible give the details of two cases of it, which have
been recently under my care. In one of them the disease was located in
the anterior horns of the lumbar, and in the other in the corresponding
portion of the cervical enlargement.
The first of these patients was an officer in the British army, aged 31,
single, of healthy parents, and temperate habits. He had entered the
army in 1864; had from that time until 1869 been stationed in the North-
ern Provinces of India, and afterwards at various places in England. In
1874 he was sent to Malta, where he remained three years. At that time
he was in the habit of taking violent exercise, as he found himself getting
stout; he used to ride much on horseback, and played at rackets for two
or three hours daily, which threw him into a violent perspiration. On
June 2oth, 1877, he was out taking exercise in a very powerful sun, and
towards evening took a bath in the sea. The water felt very chilly, but
he nevertheless remained about three-quarters of an hour in it ; sometimes
standing about on the shore, and then getting back into the water. On
coming out at last he felt benumbed, and in the night had acute pain in
the small of the back and the legs. He could not recline nor sit still for
even a few minutes, and felt so restless that he did not sleep at all, but
kept walking about in his rooms all night. Hot fomentations relieved the
pain, but only for a short time, and he was much exhausted in the morn-
ing. On the second day the pain was not so acute ; he could walk about
without assistance, but the back felt stiff and the legs ached. Towards
evening of the same day he could not walk so well ; he had to hold on to
the shoulders of two brother officers, and the right leg dragged. He could
pass his water without difficulty. There was loss of appetite ; he only
took a little soup. Hot sponging relieved him, and made the limbs feel
easier for a short time. At night he had an opiate, and he slept for six-
teen hours consecutively, perspiring profusely all the time.
On awakening on the morning of the third day he felt exhausted, and
he found that his legs had become entirely powerless from the hips down-
wards ; he could only move them with his hands. The acute pain was
gone, a dull aching only being felt. The back and loins felt very stiff,
and he could not turn over in bed, showing paralysis of the muscles of the
loins. The legs were tender to the touch, and the feet sore when handled.
He had to strain a little when passing his water, and the bowels were con-
fined. The loss of appetite continued. The patient was now blistered
No. CL — April 1878. 27
410
Althaus, Acute Anterior Myelitis in the Adult.
[April
and leeched in the back. The temperature, which had previously not
been taken, was now found to be 104°, with the thermometer placed un-
der the tongue. The next night he slept a little ; the restlessness being
relieved by his position being shifted frequently. There was no feeling of
tightness around the lower portion of the body, nor any loss of sensation.
On the fourth day there was no acute pain, but the dull aching in the
back and legs continued. The patient was put into an easy-chair, and
felt better. The bowels were relieved by an enema, and the water was
passed after some delay, the streams appearing fairly strong. The appe-
tite was improved; the temperature 103°. The day and night registra-
tions of the thermometer varied but little. The legs were rubbed, which
made them comfortable, and they became red under the friction. There
was no priapism at this or at any other time.
The succeeding days were much the same. The thermometer gradually
went down to 101°, and remained at this figure for three weeks more.
The general condition improved, the bowels acted regularly, and the
water could be passed at all times. The appetite was better, and the pa-
tient slept longer without requiring to have his position changed so often,
being easier on the back than on the side. He generally spent the day
sitting in an easy-chair, which did not fatigue him. The legs, however,
now began to waste considerably.
In about three weeks the temperature had fallen to 08°, and the patient
was then given solid food. The general condition was now quite satisfac-
tory, and he began to move the toes of the left foot a little. Strychnia
was injected subcutaneously into the inner part of the thighs, and rubbing
and magneto-electricity were used for about a fortnight. He was invalided
in about the commencement, and left Malta. He went to Guernsey,
where he was treated with strychnia three times daily, and the continuous
current; with the effect that the muscles developed better and became
firmer, and in December last he came to London to place himself under
my care.
On examining him on December 13th, I found that there was complete
paralysis of motion in both lower extremities from the hips downwards.
The muscles of the loins were not paralyzed, as the patient had no diffi-
culty in turning over in bed ; there was no movement whatever in the
ankle-joint, the knees, and the hips, but the toes of the left foot could be
slightly flexed. Faradization of the nerves and muscles of the lower
extremities did not produce any response at all, even if the power of the
current was increased to the maximum strength by the double-celled coil
of Stohrer's apparatus, which caused an almost intolerable sensation
of pricking and burning; yet not the slightest fibrillary twitches occurred
in any of the muscles acted upon. The continuous voltaic current had no
influence on the nerves, but, when applied directly to the muscular sub-
stance, caused sluggish contractions, more particularly in the left leg.
Making with the anode had most effect, closing with the cathode less, and
opening with either poles was quite ineffectual. There was no muscular
rigidity anywhere, all the muscles being completely flabby and relaxed,
and offering no resistance to passive movements impressed upon them.
They had a doughy feel, and, as there was not much wasting in the limbs,
a transformation of some portion of muscular tissue into fat could be
assumed with a high degree of probability.
Sensation was perfectly normal, there being neither pain nor paresthesia
nor anesthesia. Pressure on, and percussion of, the spine did not show
1878.] Aithaus, Acute Anterior Myelitis in the Adult. 411
any tender points ; a hot sponge could be carried along the back without
giving rise to a feeling of soreness ; and faradization and galvanization of
the spine showed it to be in its ordinary condition of sensibility. The
senses of touch, of temperature, of locality, and all the other varieties of
sensation in the lower extremities were likewise normal.
Reflex excitability, on the other hand, was completely abolished.
Tickling the soles and the knees, and irritation of the inner surface of the
thighs, were well perceived, but did not cause any movements in the paral-
yzed limbs. Percussion of the tendon of the rectus femoris and of the
tendo Achillis, remained likewise ineffectual.
The temperature of the limbs was 9-4° to 95°. The skin was slightly
moist, oedematous, and in parts mottled. There was no decubitus,1 nor
had there been any sign of it. The sphincters were perfectly normal ;
the action of the bowels regular, the urine healthy ; nor was there any
loss of expulsive power in the bladder. Sexual desire, however, which
before the affection came on was keen, was lost, and no proper erections
nor nocturnal emissions had oocurred since the disease became developed.
Digestion, respiration, and the heart's action were quite normal. There
were no head symptoms.
On considering the peculiar features of the case, the diagnosis could
not be doubtful. As only the motion of the lower extremities was lost,
and sensation in them had not suffered ; as there was no decubitus, and
no affection of the bladder and rectum, the case was evidently one of
acute polio-myelitis,2 or inflammation of the anterior cornua of the lum-
bar enlargement of the cord, which had led to paralysis and atrophy of
the whole of the muscles of the lower extremities. The close analogy
of the symptoms with those which are observed in the majority of cases
of infantile paralysis was very striking. There had been fever, the
thermometer having run up to 104°, and remaining for more than three
weeks above the normal average. Then there had never been any head-
symptoms, which is explained by the circumstance that the brain of adults
offers more resistance to morbid influences of this kind than that of chil-
dren ; and this is more particularly so where the seat of the disease is at
a considerable distance from the brain, as in the lumbar enlargement.
Where the disease affects the upper portion of the cord, cerebral symptoms
may make their appearance in the adult, as I shall show presently by an-
other case. In the present instance there had, however, been general
malaise, with pain and tenderness in the loins and lower extremities, rest-
lessness, and complete loss of appetite. As is so well marked in infantile
paralysis, the loss of power had set in rapidly, there having been paresis
or incomplete paralysis on the second, and complete paralysis on the third
day, with total relaxation of the muscles. From that time the state of
motion had not perceptibly varied. The bladder was only to the very
slightest extent affected on the third day of the disease, but rapidly
recovered its full power. The fact that there was at no time any muscu-
1 [Decubitus is a German expression for bed-sore, and is used here in this sense. — Ed.]
2 From 7roKsoi, gray, and (amkoc, marrow.
412
Althaus, Acute Anterior Myelitis in the Adult.
lar rigidity, explains why no deformity worth speaking of took place. In
the adult, deformity is altogether less likely to occur than in children, be-
cause the joints and ligaments are firmer, and the growth of the bones is
finished at the time of the invasion of the disea.se ; and deformities occur
as a general rule only where one set of muscles is paralyzed, and another
has escaped the lesion.
The second case, which I am now going to relate, was one of acute
anterior polio-myelitis affecting the cervical enlargement" of the spinal
cord r —
M. M., a Scotch gentleman, aged thirty-four, single, of no regular occupa-
tion, came under my care in June, 1877, and gave me the following history :
In November, 1864, being then an undergraduate at Edinburgh, in good
health, and studying hard, he attended a crowded meeting in the Music
Hall of that city, during which he perspired profusely. When he came
out of doors it was snowing, with a keen northerly wind blowing. He
dined, and then walked out again for about an hour. Before returning
home he felt very chilly ; two hours later he perceived pain and stiffness
in the back of the neck, which increased on attempting to move the head.
He gradually became more chilly and drowsy, and tried hard to shake it
off, so as to be enabled to study, but to no purpose. At bedtime, the skin
being hot and dry, he took some hot whiskey and water, but continued
feverish, and lay tossing about in bed all night, very restless, and unable
to go to sleep. Next morning he got up and went to his class, but felt so
drowsy and languid that he was obliged to return home.
That afternoon he took a dose of Epsom salts, and having during the
following night to traverse long windy passages to the closet, he caught a
second chill. The two following days he was up, but did not go out. as
the excessive droivsiness and languor continued without abatement. Dur-
ing the night of the fourth day, he got out of bed for a drink ; but after
making a few steps his knees gave way suddenly, and he fell heavily on
his back. A friend with whom he was lodging had to assist him to get
up, and with some difficulty got him into bed. He now perceived a diffi-
culty in passing his water, but ultimately succeeded in doing so. Next
morning, however, he found himself entirely helpless, as the paralysis had
spread to both upper extremities. The left side of the body was com-
pletely useless, but in the right he could just move the fingers and toes a
little. All this time there was no pain, no loss of sensation, and the fever
frequently left him. The temperature was not taken at any time during
the progress of the case. He was given antimonial wine, and fell into a
profuse perspiration, which continued without intermission for about a
fortnight. The drowsiness gradually left him, the head appeared quite
unaffected, and the general health was good, for, with the exception of the
loss of power, he felt, about a month from the commencement of the dis-
ease, as well as ever he did in his life. There was, however, complete
paralysis of the left, and nearly complete loss of power in the right side.
He could not even move his head on the pillow, and for six months was
not taken out of bed.
There was never any tendency to decubitus. The condition of the
bladder varied; the patient being sometimes unable to pass his water,
so that the catheter had to be used, while generally he could pass it,
although with some difficulty. The urine would appear never to have
1878.] Althaus, Acute Anterior Myelitis in the Adult. 413
undergone those changes which are so marked in transverse myelitis, viz. :
alkaline decomposition, with formation of triple phosphates, vibriones,
bacteria, and muco-pus ; but it would seem to have been normal through-
out. The bowels were sluggish ; purgatives had no effect, and enemata
were found necessary. The treatment at this time consisted of blistering at
the back of the neck, strychnia, and the use of the magneto-electric rotatory
apparatus, which was kept grinding away at his hands, and sometimes at
the soles of the feet — a most unscientific and foolish application — three
times daily for half an hour. The electrodes were brass tubes without
handles ; the machine was used for two or three months, and the patient
believed that it did him more barm than good. He was very little better
by May of the following year, and was then takeu to his home in the
Highlands, where he began to improve considerably, and had in a month
recovered full power over the bladder and bowels. In June he went to
the Strathpeffer sulphur springs, and derived apparently some benefit from
them, for, when he returned, he could stand when put on his legs, and
walk a few steps without assistance.
During the following years he pursued various plans of treatment, more
especially different applications of electricity, arsenic, and hydropathy,
and he gradually improved, without, however, being able to attribute any
very decided result to any of them.
At the time he came under my care, nearly eleven years after the com-
mencement of the disease, there were no symptoms pointing to an affection
of the brain or cerebral nerves. Sensation was perfect all over the body,
and the general health was good. With regard to the state of motion in
the upper extremities, the patient had to a great extent recovered the
power over the right arm and hand, which he could move in all directions ;
he could write a letter, wash and dress himself, and squeezed the dyna-
mometer to the extent of 48 kilogrammes. The muscles, although not
robust, were fairly nourished, and responded fairly well to faradization and
galvanization. The left arm was much more feeble than the right. There
was some wasting of the trapezius, deltoid, and serratus muscles, causing
slight dislocation of the caput humeri ; the biceps was very feebly devel-
oped, and the flexor muscles of the forearm were also in a state of atro-
phy. The muscles of the ball of the thumb, and the first interosseous
muscles were greatly wasted. In accordance witli these symptoms the
patient had but little power in the left arm, which he could not raise above
the horizontal line ; and the hand was to a great extent useless and awk-
ward. There was, however, a degree of faradic and galvanic response,
which was in exact proportion to the general state of motion in and nutri-
tion of the muscles. Reflex excitability was normal in the right, and
somewhat reduced in the left arm. With regard to the lower extremities,
it was found that, when once fairly on his feet, he could walk with the aid
of a stick for about two hundred yards. After doing that distance, how-
ever, the back became painful, and the patient got out of breath, so that
he was obliged to rest. With crutches he could walk several miles. He
could stand for hours without fatigue, while he was always worse after
sitting for a long time. He had great difficulty in turning in bed, and in
undressing, and was generally unwieldy. The left leg was much more
powerless than the right ; and there was much greater atrophy in the
muscles of the left thigh and leg. Nevertheless, what was left of these
muscles responded well to galvanization and faradization, and there was
uo lack of reflex excitability in the lower limbs, both as far as skin and
414 Alt HAt s, Acute Anterior Myelitis in the Adult. [April
tendons were concerned. Apart from the unsatisfactory state of motion,
the patient was in every respect in perfect health.
From this description it will be seen that the two cases of acute anterior
polio-myelitis which I have just described were in most respects exceed-
ingly similar. In both the cause was evidently cold ; although it does
appear singular that both patients had often before been exposed to chills
on a heated body without having been any the worse for it. More es-
pecially the subject of the second case was brought up inured to hardi-
hood, and could with perfect impunity endure severe and prolonged
exposure to heat, wet, and cold ; and even at the present time a thorough
drenching and sitting in wet clothes would not affect him. Moreover,
both patients had numberless times before experienced much more severe
chills and colds than the one after which the myelitis became developed ;
and it appears, therefore, probable that in both cases there must, at the
time of the invasion of the disease, have been a state of diminished re-
sistance of the cord to unfavourable influences. Neither of the patients
had the neurotic constitution ; neither had had syphilis. In both there
were fever and systemic disturbance at the commencement ; in the
former, Avhere the lumbar enlargement was affected, the head remained
perfectly clear, and there was only great restlessness ; while in the latter,
where the cervical enlargement suffered, there were, in addition to rest-
lessness, great drowsiness and languor. In both there was profuse per-
spiration at an early period of the disease ; and the paralysis was quickly
produced, and remained exactly the same for a considerable time. "Where
the lumbar enlargement suffered, the bladder was hardly at all affected,
while in the case of cervical polio-myelitis the bladder suffered as far as
its expulsive power was concerned, but recovered its tone at a compara-
tively early period.
There are few diseases which could be confounded with acute anterior
myelitis. Hemorrhage into the spinal cord may produce sudden paralysis,
which is followed by atrophy and loss of reflex excitability ; but there is
an absence of fever, the invasion of the paralysis is still more sudden, as
it generally comes on in a quarter of an hour or even less, and there is
anaesthesia, paralysis of the sphincters, and decubitus.
In acute central or transverse myelitis there is always anaesthesia of the
skin, paralysis of the sphincters, and tendency to decubitus, by which that
disease is sufficiently well distinguished from acute anterior polio-myelitis.
Progressive muscular atrophy is very chronic in its invasion, and there
is wasting of muscular tissue before the paralysis sets in. There are many
other distinctive features between these two diseases, but the two I have
just mentioned are quite sufficient to enable us to make a proper diagnosis.
Brown-Se:mard's spinal hemiplegia or hemiparaplegia could hardly
be confounded with anterior polio-myelitis. It is true that there is motor
paralysis, affecting either the leg alone, or the arm and leg of the same
1878.] Althaus, Acute Anterior Myelitis in the Adult. 415
side ; but while in polio-myelitis sensibility remains normal, there is in
Brown-Sequard's disease hyperesthesia on the paralyzed, and anaesthesia
on the opposite side, which renders the diagnosis certain.
From cerebral hemiplegia anteriov polio-myelitis may be distinguished
by the different commencement of the paralysis ; by the affections of cere-
bral nerves which accompany cerebral paralysis, and particularly by the
circumstance that in cerebral paralysis the farado-muscular excitability
remains unaltered, or nearly so, for years after the invasion of the disease,
while in polio-myelitis it is lost in the second week.
Sclerosis of the lateral columns of the cord resembles anterior myelitis
by there being no affection of sensibility, no decubitus, and no paralysis of
sphincters ; but the invasion of the complaint is essentially chronic ; and
incomplete or complete paralysis, with muscular rigidity and increased
reflex excitability, more especially of tendons, are the chief symptoms.
Where the patient is able to walk, he shows a peculiarly rigid or spastic
gait, which is entirely different from the halting and lame gait of a man
suffering from chronic myelitis, as well as from the jerky and uncertain
walk which is seen in locomotor ataxy.
Sclerosis of the lateral columns may, however, coexist with wasting of
the anterior cornua, and this constitutes a disease which Charcot has re-
cently described as lateral amyotrophic sclerosis. This mostly begins in
the upper extremities, which become more or less paralyzed and wasted,
while the antagonists of the paralyzed muscles become rigid and contracted.
The consequence of this is, that the arm is held tightly to the body, the
forearm flexed and pronated, the hands and fingers strongly flexed. After
this has existed for some months, the disease progresses to the lower ex-
tremities, causing incomplete or complete paralysis witli rigidity. There
is no anaesthesia, no decubitus, no paralysis of sphincters. After a time
the rigid muscles begin likewise to waste, when the contractions disappear.
Death takes place by the degeneration attacking the motor nuclei in the
medulla oblongata, with consequent paralysis of the lips, tongue, pharynx,
and larynx, that is labio-glosso-pharyngeal paralysis. The chronic and
progressive course of the disease is sufficient to distinguish it from polio-
myelitis, the onset of which is rapid.
If we consider the well-marked symptoms of the disease to which I have
directed attention in this paper, we can entertain no doubt that we have
to do with an acute inflammation of the anterior gray matter, which affects
principally the lumbar or cervical enlargement of the cord. The large
ganglionic cells of the anterior horns are partly motor and partly trophic
in their functions, while the small vesicular ones of Clarke's columns are
sentient, and the smallest posterior ones vasomotor or sympathetic. In
accordance with this, we find in the two cases which I have related
paralysis of motion and of nutrition in the affected motor nerves and mus-
cles, but no affection of sensibility or of the vaso-motor system of nerves.
416 Althaus, Acute Anterior Myelitis in the Adult.
If we could have made an inspection of the cord in these cases, we should
have discovered an acute inflammation of the anterior horns ; distension
and attenuation of the nerve-sheaths ; swelling and division of the axis
cylinders ; oedematous degeneration and destruction of the ganglionic
cells ; swelling of the fibres of the neuroglia and proliferation of its nuclei ;
and dilatation of the arterioles and small veins, with rupture of the capil-
lary vessels and effusion of blood ; in short, all the signs of red, and after-
wards yellow, softening of the substance of that portion of the cord, the
inflammation being probably parenchymatous as well as interstitial.
A matter of extreme interest in these cases is the relation of the para-
lyzed nerves and muscles to the different forms of electricity. Until quite
recently it was believed that the peculiar phenomena which I have de-
scribed above were characteristic for peripheral paralysis, from injury or
lesions of the nerves ; but it has been shown that they occur likewise in
infantile paralysis i and in acute anterior myelitis of the adult. There is
complete loss of faradic excitability of the nerves, as well as of the mus-
cles ; complete loss of voltaic excitability of the turves; but exaltation of
voltaic excitability of the muscles in the early stage, and preservation of
the same in the later stages of these diseases. These changes correspond
closely to the degeneration which is going on in the nerves and muscles,
after these have been separated from their centres of nutrition, either by a
break in the continuity of conduction between centre and periphery —
peripheral paralysis, or by actual destruction of the nutritive centres —
anterior myelitis ; and they are to a great extent accounted for by differ-
ences in the duration of the several currents. Faradism, which consists
of a number of instantaneous currents succeeding each other rapidly, has
no effect at all ; a continuous voltaic current, which is by an artificial
arrangement rendered short or instantaneous, has little or no effect, even
if the current-force be considerable ; while a voltaic current of long dura-
tion, even if it be comparatively feeble, has a considerable action, which
increases proportionately to the length of time during which it passes
through the structures acted upon. We are as yet, however, entirely un-
able to explain the rationale of the exalted volta-muscular excitability
which is found in these conditions.
The prognosis of acute anterior myelitis is not favourable, since com-
plete recovery is the exception, not the rule. This is more especially so
where the acute attack is treated in the old-fashioned routine manner, of
which I shall speak presently. It is, however, rare, even where the treat-
ment has been inefficient, that not some amount of improvement ultimately
takes place ; and patients mostly regain in time some use of their limbs,
more particularly if they are young and vigorous at the time they are
attacked by the disease. The prognosis will no doubt be very much better
when the disease comes to be more thoroughly understood, and is specifi-
cally treated from its very commencement.
1878.] Ax thai'S, Acute Anterior Myelitis in the Adult. 417
The treatment of myelitis which is generally recommended, consists, as
long as there is fever, of rest in bed, calomel, leeches, and cupping to the
spine, more especially the region of the cervical and lumbar enlargement,
rubbing in of mercurial ointment, and counter-irritation by tincture of
iodine and blisters. With the exception of rest and a scanty diet, I
believe these measures to be useless, and have, therefore, ceased to employ
them. The only remedy in which I have any confidence in the acute
stage of the disease is the subcutaneous injection of ergotine. Ergotine is
known to have the power of contracting the bloodvessels of the spinal
cord, more especially when it is directly introduced into the circulation,
without the intervention of the stomach; and as intense hyperemia of the
arterioles, small veins, and bursting of capillary vessels of the cord from
excessive distension, is one of the characteristic anatomical features of the
disease, ergotine appears to be a direct antidote to that condition. I use
a solution of Bonjean's ergotine in distilled water, which, if thoroughly
pure, is generally not irritating; and of this I inject a grain as a dose to
begin with. Our guide in carrying out this treatment must be the ther-
mometer and the pupil. Where the temperature runs up to 104° or 105°,
the remedy should be more freely used than where the fever is slight ;
in severe cases three grains may be injected at a time, and this may be
repeated two or three times a day. The fever being in all these a second-
ary phenomenon, consequent upon local inflammation, may be rapidly
reduced by the use of the ergotine, which thus proves a truly antiphlo-
gistic remedy. Where the pupil becomes very much contracted, and con-
tinues so for some time, it is better to wait before making a fresh injection.
This treatment should be continued until the temperature has fallen to the
normal standard. The place of injection is, on the whole, a matter of
indifference; but, where the lumbar enlargement suffers, I generally inject
in the leg ; and where the cervical enlargement is inflamed, I prefer the
arm.
Such is the treatment I recommend for the attack itself. As soon,
however, as the inflammation has subsided, the ergotine must be discon-
tinued, and iodide of potassium in doses varying from ten to twenty
grains, several times a day, be substituted for it. This serves to induce
the absorption of inflammatory effusions, and to check the excessive growth
of connective tissue which is liable to Aoav, and thus allows those gan-
glionic cells, which have not been entirely destroyed by the disease, the
possibility of recovery. The constant voltaic current should now also at
once be used, and be made to pass through the diseased portion of the
cord. If the legs only are affected, the current should be directed to the
lumbar enlargement, the positive electrode being placed to the loins, and
the negative to the umbilicus. Where the arms or all four extremities
suffer, the cervical enlargement should be principally acted upon, and the
anode is then placed to the nape of the neck, and the cathode in front of
418
Althaus, Acute Anterior Myelitis in the Adult. [April
the throat. Where we have reason to assume that the dorsal portion of
the cord is implicated, this should likewise receive the voltaic influence.
Erb, of Heidelberg, has recommended to send the current first in one di-
rection, and then in another, so as to utilize the influence of either of the
poles to the diseased parts. From general considerations of the catalytic
effects of the current, however, the action of the anode appears to me to
be most called for; and I should, therefore, employ Erb's proceeding only
if the mode of application which I have just recommended should fail to
produce the desired effect. The electrodes should be large, the current-
force gentle, and the application continued for from three to ten minutes,
according to the extent of the lesion.
An early resort to this mode of voltaic treatment is of the greatest im-
portance ; for if the ganglionic cells, which resisted destruction in the first
instance, have in the course of time become compressed and squeezed by
excessive development of connective tissue, only little can be expected of
any therapeutical measures.
Where the case comes under treatment, as is only too frequently the
case, six months or longer after the commencement of the disease, we have
to do more with the consequences of the attack than with an actively pro-
gressing pathological event. Iodide of potassium is now useless, and small
doses of phosphorus and cod-liver oil are now the best medicines for im-
proving the nutrition of the nervous matter. The phosphorized cod-liver
oil, prepared many years ago at my suggestion by Messrs. Savor}- &
Moore, of London, is a very useful preparation at this stage. Subcuta-
neous injections of strychnia, which are much employed, have not in my
hands yielded those results which would appear to have been seen by other
observers; and I cannot, therefore, recommend their use. Mountainous
or sea air, the thermal springs of Kehme, Wildbad. Toplitz. and Gastein,
and a nutritious and even stimulating diet are more useful. The voltaic
current may also be applied to the seat of the disease in the cord in the
way just described; but as we have at this stage to do with wasting of
the paralyzed nerves and muscles, a peripheral application of the current,
alternating with faradization, may iioav be employed. Gymnastic exercises
of the muscles, shampooing, and friction of the paralyzed limbs with lini-
mentum ammonia?, and other stimulating applications, are useful auxilia-
ries in the treatment of these conditions.
1878.]
TT o a k e s , Stomachic and Labyrinthine Vertigo.
419
Article XIII.
The Connection between Stomachic axd Labyrinthine Vertigo.
By Edward Woakes, M.D., London, Surgeon to the Hospital for Diseases
of the Throat and Chest, and to the Metropolitan Dispensary for Diseases of
the Ear, London.
A great deal of attention has recently been devoted to what is com-
monly called Meniere's disease, but which, from the anatomical organ to
which the symptoms are mainly referred, is also known as labyrinthine
vertigo. The elaborate treatment of Dr. Gowers, Dr. Hughlings Jackson,
and Dr. Ferrier, compasses the present knowledge of the subject, so far
as it relates to that form of vertigo resulting from the progressive invasion
of the labyrinth from lesions of the middle ear.
But there is another class of vertiginous patients in whom the auditory
apparatus is, up to the time of the attack, perfectly healthy, and may re-
main so after it has passed off, whose symptoms are nevertheless due to a
more or less temporary lesion of the labyrinth, to which organ, in fact,
the general consensus of opinion refers every such disturbance of equi-
libration as expresses itself in giddiness. It is to this class of cases I wish
to invite attention, and as in their investigation we shall get some insight
into stomachic vertigo, the area of interest of the subject will be propor-
tionately widened.
The form of vertigo to which I allude is that in which the patient,
without being aware that he is otherwise than quite well, is suddenly
attacked with giddiness, and falls prostrate. This may never, in that
patient's experience, be repeated ; or the attack may recur after a shorter
or longer period. The cases in question differentiate themselves from
those treated of by the authors referred to in the fact already stated that
the auditory apparatus is previously quite healthy, though they possess
this feature in common with them that there is no loss of consciousness.
After the attack the patient finds himself in one of the following condi-
tions : his hearing may be normal as heretofore ; or he may be quite deaf
on the side to which he fell; or there may remain some impairment of
hearing only, with probably confused noises in the head.
As regards concomitant symptoms, nausea and a splitting headache may
remain. There is also a painful sense of fear, a horror lest the attack
should be repeated, and a dread of becoming epileptic ; to which appre-
hension the members of our profession who suffer from the attacks are
specially prone.
The following example, the subject of which was a medical man, per-
sonally known to me, illustrates some of these features: —
When about thirty years of age, and being fully engaged in a very
arduous country practice, he was one evening summoned to a patient,
being already fatigued with the usual day's work. On reaching the house
420 Woakes, Stomachic and Labyrinthine Vertigo. [April
he became giddy, and, as the door was opened, fell into the hall, a pro-
ceeding which, though perfectly conscious, he was quite unable to avoid.
It is needless to say he was very much frightened by the attack, but was
not otherwise affected by it. In the course of the following year a second
seizure occurred exactly corresponding in character to the former, but for
more than twenty years subsequently there was no repetition of the at-
tack, although he was for a lengthened period the subject of intense head-
aches, with tinnitus, for which he submitted to the ordinary method of,
depletion then in vogue. The time at which these events happened was
over thirty years ago, when Meniere's disease was of course unheard of
and Flourens had not yet experimented on the semicircular canals. It was
not, therefore, extraordinary that this patient should be haunted with the
dread of becoming epileptic. So much, in fact, was this the case that lie
frequently devised the course he should pursue should he be attacked when
riding over the country roads of his district.
These details are important, as they illustrate the undefined terror dis-
played by the subjects of labyrinthine vertigo; and though no deafness
existed as their result, the symptoms are such as help to separate the
disease from others cognate to it.
Adhering to the principle laid down in a former paper, we shall seek
the clue to the symptoms in the source and vaso-motor relations of the
bloodvessels supplied to the region manifesting them; a proceeding which
will show that this particular region, the labyrinth, possesses some very
remote, and possibly unlooked-for alliances.
At this point it will be necessary to repeat what I have elsewhere had
occasion to insist upon, viz., that the receptive part of the auditory appa-
ratus receives its vascular supply from a totally distinct source — the verte-
bral artery — to that which is furnished to the conductive portion of the
ear. This, in itself, is a suggestive fact, as the internal carotid in its bony
canal is placed so close to the internal ear that one might naturally look to
it as the source whence its vessels would be derived. As a matter of fact,
however, neither the external nor internal carotid is in any way concerned
with the circulation of the labyrinth. It is the vertebral artery and its
relations we have to consider. The origin of this vessel from the sub-
clavian deep down in the neck, and its prolonged course upwards, guarded
by the bony sheath formed by the vertebral foramina, acquire an increased
importance when its relations to certain nerves are considered. In the
first place, this position brings it into very close proximity with the infe-
rior cervical ganglion, from which it derives a rich plexus of nerves, com-
municating in their upward course with the several cords which form the
brachial plexus.
It is important here to note that this lower cervical ganglion furnishes
also the principal inhibitory nerve of the heart, viz., the inferior cardiac
nerve. The experiments of Burdon Sanderson and others show that this
nerve is capable of slowing the heart's action, even to the extent of stop-
ping it ; we wish to point out its close relationship wTith the nerve which
regulates the supply of blood to the labyrinth, both passing through the
1878.] Woakes, Stomachic and Labyrinthine Vertigo.
421
same sympathetic ganglion. Nor can it be without design that such an
arrangement exists. Glancing for a moment at one aspect only of the
functions of the semicircular canals, that, viz., by which, under circum-
stances of altered tension of their enclolymph, they are capable of causing
the individual to lose his equilibrium and fall to the ground, we get some
insight into the object gained by associating the nerve which regulates
this tension with that which tends to check the heart's action. The con-
nection is such that an impression influencing the heart will affect the
labyrinth. Thus a strong mental emotion arising centrally and propa-
gated to the heart through its inhibitory nerve, which tends to stop its
action, will also be deflected in the ganglion to the nerve regulating the
blood supply of the labyrinth, and by suddenly changing the tension in
this organ will cause the subject to fall to the ground, so removing the
mechanical impediment to the circulation which the upright posture im-
plies. In this way time is allowed for the excited influence of the heart
to subside, while the subject of it is placed perforce in the recumbent
attitude.
Referring now to the communications between this ganglion and the
brachial nerves, besides those already mentioned, there are others pro-
ceeding directly from the ganglion to the brachial plexus. It is this
arrangement, doubtless, which explains an occurrence noticed in gunshot
wounds of this plexus. It was first pointed out by Drs. Mitchell, Moore-
house, and Keen in a treatise on gunshot wounds of nerves, published
after the late American war. These observers record most succinctly
that the subject of such a wound, whether received in the arm, axilla, or
neck, immediately falls to the ground, without losing consciousness. This
circumstance is quite unique ; it has not been observed in connection with
wounds of any other correspondingly non-vital part of the body. A cer-
tain amount of collapse attends these cases, from which it may be legiti-
mately inferred that the shock is conveyed not only in the direction of the
labyrinth, but also through its inhibitory nerve to the heart.
Any one who is conscious of the possession of what is popularly called
the "funny bone," may, if he chooses, verify these statements, at least to
a certain extent, by giving it a blow considerably in excess of that which
is sufficient to infuse the well-known tingling sensations in the fingers.
It once happened to the writer to witness such an experiment in the
instance of a lad who was struck on this spot by a hard tennis-ball thrown
with considerable violence. Immediately he became giddy and confused
in his head, and would have fallen but for the support of some railings,
and altogether the extreme distress which he manifested appeared out of
all proportion to the slightness of the cause. At. the time of the occur-
rence the symptoms were quite inexplicable by any known relations of
the injured part. The observations of the American surgeons just quoted,
as well as the anatomical continuity established through the infra-cervical
422
Woakes, Stomachic and Labyrinthine Vertigo. [April
ganglion between the brachial nerves and the labyrinthine circulation,
aiford, we venture to submit, a ready explanation of the phenomena to
any one who candidly examines them.
It will be apparent that we are taking for granted the physiological fact
that a shock communicated to the inhibitory nerve of a vessel temporarily
withdraws its function, allowing it to become greatly distended with
blood ; it is this sudden distension which produces the pressure on the
endolymph, and the consequent subversion of the function of equilibration,
which will be proportionate to the severity of the shock.
Having thus seen how labyrinthine vertigo of a very severe type may
be excited through these far-off alliances of the semicircular canals, we
shall be in a better position to understand the corresponding relations
existing between the stomach, with its adjacent viscera, and the labyrinth.
Before tracing these, it will be of service to refer to Trousseau's remarks
on this subject, he being probably the first writer to call marked attention
to stomach vertiyo in his chapter entitled "Vertigo a Stomacho La?so,"
where he discusses it with his usual candor. No one, we venture to
think, can carefully study the instances he adduces of this disease without
sharing the conviction that the gastric lesion was only a subsidiary factor
in the production of the symptoms he refers to it. That Trousseau had
himself some suspicions of this is evidenced by his own statement. Thus,
after describing the case of a lady in whom distressing giddiness, brought
on by the bustle of the streets, the passing of a carriage in rapid motion —
causes exactly calculated to interfere with the organ of equilibration when
unduly susceptible — and who became worse by depletion and abstinence
from generous diet, but was cured by tonics and restoratives, remarks. " I
have frequently asked myself whether the treatment which in these cases
I directed against the affection of the stomach was not, unknown to me,
addressed to the nervous system ; and whether I had not diagnosed a gas-
tric affection, rather from the effect of treatment, than from the symptoms
of the disease; whether I had not been led into an error in diagnosis, by
obtaining success from treatment usually employed with benefit in dyspep-
sia."1
In this candid commentary, my own experience of so-called stomach
vertigo would lead me entirely to concur. A fair example is afforded in
the following case : —
A gentleman, a member of the Society of Friends, consulted me some
five years ago for symptoms closely corresponding with those enumerated
in the foregoing quotation. He was about 73 years of age, and though never
robust, was otherwise in good health, except that any exertion brought on
giddiness, and walking in the streets was attended with a feeling that he
would fall forwards. His appetite was good, although the tongue was
loaded, and it was observed he had no teeth, not even artificial ones, but
it was ascertained that he ate meat with a relish. In view of the edentu-
1 ''Lectures on Clinical Medicine," New Syd. Soc. Ed. vol. 3, p. 544.
1878.] "Woakes, Stomachic and Labyrinthine Vertigo. 423
lous state of his jaws, and with Trousseau's teaching in recent recollection,
he was prohibited taking any solid food ; small doses of bromide of potassium
were given at six hour intervals. Under this treatment he made a rapid
recovery. After an interval of nearly a year he returned to a mixed diet,
and in a short time his old symptoms returned, but to a less extent than
formerly. The same treatment was again had recourse to with a like
result, and in the period that has since elapsed the role of circumstances
just detailed has been enacted on several occasions. In fact, the sensitive-
ness of this patient's stomach to solid food appears to be proportionate to
the motility of his equilibrating nervous centre.
It is a suggestive feature of this case, as also of others that have occurred
to me, that the progress towards recovery was invariably expedited by
the bromide. Obviously, the point at issue is, how to associate stomach
vertigo with the labyrinth. A very direct channel of communication is
established between the pneumogastric nerve and the lower cervical gan-
glion by means of a fasciculus given off by the former about the point
where the recurrent laryngeal leaves the trunk of the nerve. That the
course of this branch is from the stomach to the ganglion will be apparent
when it is remembered that vaso-motor fibres associated with cerebro-
spinal nerves pursue an opposite course to the latter. When it is further
remembered that nerves entering a ganglion break up and communicate
with its corpuscles, by which means they contract new relationships with
other nerves entering the ganglion, it will not be difficult to understand
how the stomach is brought into relationship with the labyrinth. There
can, we think, be no doubt that this correlation is effected in the inferior
cervical ganglion, through the medium of the - communication just noted
from the pneumogastric to the ganglion, impressions passing along which
become in it transferred to the inhibitory nerves furnished to the vertebral
artery from the ganglion.
Having established this relationship anatomically, it seems impossible
not to observe the analogy existing between the shock propagated from a
contused brachial nerve to the vertebral artery, with its concomitant ver-
tigo, and the lesser shock caused to the nerves of the stomach by the
lumps of unchewed meat swallowed by the toothless patient, and propa-
gated thence to the same vessel and attended with the same condition, viz.,
giddiness. Mutatis mutandis, the cause, the method, and the result, are
one and the same thing ; the experiment is the same ; the conditions only
are varied. Hence it would seem that nature had in the labyrinth erected
a signal box in which a note of warning might be sounded by the much
abused, though tolerant, viscus, the stomach, whenever the ill treatment it
is subjected to threatens to compromise more vital parts of the organism.
It would seem to teach us what the acquired wisdom of advancing years
so often fails to do, that the senile stomach is not the fit receptacle of un-
masticated meat ; that it resents the slight shown it in this, and, of course,
in many other ways ; first of all by the warning attacks of giddiness,
which, if not heeded, will shortly culminate in a fall. It was by such a catas-
42-4 Woakes, Stomachic and Labyrinthine Vertigo. [April
trophe that the Duke of Wellington lost his life — the unscathed hero of a
hundred fights failed to prove himself master of the situation when the
forces arrayed against him were a vigorous appetite and an acutely sympa-
thetic labyrinthine circulation.
These observations naturally lead us to infer that the doubts which in-
stigated Trousseau to ask himself the question, whether u the treatment
which in these cases he directed against the affection of the stomach was
not, unknown to him, addressed to the nervous system," were well founded.
The fact is it was directed to both. By resting and restoring the digestive
apparatus, he appeased those waves of excited vaso-motor sympathy exist-
ing between this viscus and the important tissue tracts supplied by the
vertebral artery.
The establishment of a communication between the inferior cervical
ganglion and the viscera through the pneumogastric nerve suggests an
explanation of some other phenomena which frequently accompany indi-
gestion, but which occur in distant organs. As, however, they are not
vertiginous in their character, we shall only glance at them in passing.
One of these is shoulder -tip pain and pain in some other region of the
shoulder, which is popularly associated with indigestion or liver derange-
ment. Explained by the facts we are considering, this pain would mean
that a morbid impression has been reflected from any portion of the prima?
via? to which the pneumogastric is distributed to the lower cervical gan-
glion, through the channel above indicated. Thence it is passed to the
plexus proceeding from the ganglion for distribution over the subclavian
artery and its branches, which plexus constitutes the inhibitory nerves of
this section of the circulation, including the vasi nervorum of the brachial
nerves. One of these nerves, the supra-scapular, is unique in its course,
inasmuch as it passes beneath the ligament of the notch of the spinous pro-
cess in its course to the muscles of the dorsum of this bone (supra and infra
spinati), in which confined position a very little swelling will be appre-
ciated as pain in its terminal branches. This amount of swelling will be
afforded, as we have had frequent occasion to see, by the dilatation of the
vasi nervorum when their inhibition is suspended ; an effect which happens
as the result of the impression conveyed from the stomach. Of a similar
character and origin doubtless is the pain in other brachial nerves, which
frequently is associated with indigestion, also occurring in heart lesion,
whether functional or organic, the association in this case being derived
through the cardiac nerve. Hiccough may own a corresponding origin
through irritation of the phrenic nerve by dilatation of the comes nervi
phrenici, inducing spasm of the diaphragm. Such a relationship receives
corroboration from the case of .an aged patient, who suffered from vertigo
and illusions, with constant hiccough, which would last for days together.
In this instance also bromide of potassium afforded great relief. That
motor excitement, as well as sensory derangement, should result from the
1878.] Woakes, Stomachic and Labyrinthine Vertigo.
425
conditions under review is instanced by a patient of, I believe, Dr.
Gower, in whom automatic movements of the arm were associated with
labyrinthine vertigo from disease of the middle ear. That these various
and distant tissue tracts are really correlated through the medium of the
ganglion in question receives confirmative evidence from the effects of cer-
tain drugs. Thus tobacco will produce giddiness, tinnitus, nausea, pre-
cordial distress, and aching in the arms, among other conditions, indicating
its progressive influence over the centres of the sympathetic system. Qui-
nia, again, in large doses, produces giddiness, tinnitus, and occasionally,
in extreme cinchonism, such trophic changes in the upper extremity that
the cuticle will be shed like a glove. Both these drugs, therefore, may be
viewed as having a paralyzing influence over the inhibition of the lower
cervical ganglion. The bromides, and notably hydrobromic acid, have an
opposite effect, because they annihilate the aural symptoms of quinia, cure
labyrinthine tinnitus ; coupled with suitable diet they remove stomachic
vertigo, and have proved highly serviceable in a case of associated hiccough.
They have, moreover, a now well-established therapeutic relation to epi-
lepsy. But the fact that the treatment of epilepsy, however conducted, is
greatly influenced by the diet, that the absolute withdrawal of solid food
immensely expedites recovery — a circumstance which I have repeatedly
proved — this fact, we say, pointing to a direct influence between the inner-
vation of the stomach and the condition of tone of the vertebral artery, is
strongly confirmative of the reality of the correlation advocated in this paper.
From the foregoing remarks it will be seen that we have in the inferior
cervical ganglion an organ for connecting the upper extremities,, the heart,
the stomach, and upper portions of the digestive apparatus with the laby-
rinth. These relationships, in all probability, by no means exhaust its
range of influence, but they suffice the objects of this discussion. The
ganglion in question brings these widely separated regions into very inti-
mate sympathy, by virtue of its regulatory power over the blood supply of
the labyrinth and of its afferent and efferent branches to the organs re-
ferred to. Returning to the case of the toothless patient,, who suffered
from vertigo whenever he partook of solid food,, we take the following to
be the course of events in this, as probably in all cases of giddiness which
originate in the stomach. The ingestion of the irritant gives rise to an
impression which is conveyed along the channel already indicated as form-
ing a communication between the pneumogastric nerve and the inferior
cervical ganglion, whence it is reflected to the vertebral artery in the shape
of a wave of diminished inhibition. This is equivalent to an increased
flow of blood to the labyrinth with corresponding pressure on the endo-
lymph. This pressure physiologically interpreted means giddiness, so far
as it relates to the semicircular canals, and when, as usually happens, the
circulation of the cochlea also becomes hyperamiic, there is concomitant
tinnitus of a more or less pulsating character. If the vascular dilatation
No. CL April 1878. 28
426
Webb, Is Phthisis PuTmonalis Contagious?
[April
admits of effusion of serum deafness is superadded, and if the exudation
partake of the more solid particles of the blood, so that a clot is formed,
the deafness may be permanent. In the milder occurrence the impression
will be transitory, passing away with the removal of the exciting cause.
It is to be noted that the labyrinth is placed at the extreme peri-
phery of the tract supplied by the vertebral artery ; it will therefore be the
first to appreciate the consequences of the wave of suspended inhibition
communicated to it from the ganglion. The phenomena it occasions
under these circumstances are of such a marked character that they can-
not fail of attracting the patient's notice : whether the impression origi-
nate in the heart, the upper extremities, or the digestive organs ; the first
note of warning is thus usually struck in the labyrinth. We are therefore
justified in regarding this organ as possessing a sentinel-like office to warn
the subject of changes of blood supply about to happen throughout the
whole of the important regions supplied by the vertebral artery, such,
for instance, as the medulla oblongata, and the contiguous nerve centres
at the base of the brain. Hence epilepsy and apoplexy may be about to
supervene ; the petit mal of the former disease being the signal note of the
labyrinth, betokening the condition of its circulation, and suggesting the
search for sources of suspended nerve inhibition.
In the disturbance of some one or more of the multitudinous sympathies
thus imperfectly sketched will be found an explanation of the occurrence
of those simple attacks of labyrinthine vertigo which come on without any
previously existing ear disease, the desire to understand which furnished
the key-note to this paper.
If the argument we have attempted to establish be accepted as proven
— or, if not yet sufficiently tested, should it receive ultimate demonstration
— a most important fact will become apparent, viz., that the ganglia of
the sympathetic system are endowed with the function of correlating
widely separated organs or tissue tracts. That is, they bring distant re-
gions into such mutual relationship that it is impossible for one of them to
undergo any alteration in its normal state without a corresponding change
being ipso facto set on foot in some more or less distant region with which
the vaso-motor fibrillar of a given ganglion connect it.
Article XIV.
Is Phthisis Pulmonalis Contagious, axd does it belong to the
Zymotic Group? By W. H. Webb, M/D., of Philadelphia.
One of the most important and interesting questions in connection with
phthisis, and one on which great diversity of opinion exists, is that of its
contagiousness. From time immemorial this disease has existed, and is
justly regarded as the most insidious and dangerous of all pulmonary affec-
1878.]
Webb, Is Phthisis Pulmonalis Contagious?
427
tions. It heads the mortality list of nearly every civilized country, and
its mode of propagation, therefore, becomes an extremely important sub-
ject for study.
In Philadelphia the total mortality, for a period of ten years, from 1867
to 1876, as shown by the Board of Health Reports, was 165,052. Of
this 13| per cent, was from phthisis, and of this number 50t9q per cent,
were females, and 49^ per cent, were males, showing an excess of If per
cent, of the former over the latter.
The following case of pulmonary phthisis from contagion occurred in
the practice of the writer, and led to the study, the result of which is given
in the present article : —
In January, 1874, 1 was requested to attend Mrs. S., aged 24 years, who was
suffering from phthisis ; it was found difficult at first to convince her parents,
as also her husband, that that was the real cause of her illness, as they
stated that, " Consumption was not known in the family of either father
or mother, that her maternal grandmother was still living, now a lady
seventy-five years old, and healthy in every particular, and that her
paternal grandfather, aged eighty-one years, was accidentally drowned
about two years ago, while endeavouring to drive across a ford, during
high water, of one of the streams of West Virginia. Both families are long
lived." On making further inquiry, it was . found that during the winter
and spring of 1873 she was in constant attendance upon a lady friend who
had phthisis, and for whom she had the most fond attachment, and who
died in May of that year. Mrs. S. was not married at that time. She
died the latter part of March, 1874.
On considering the question of the contagiousness of phthisis it is im-
portant to clearly understand what is meant by the term, and there is a
diversity of opinion in regard to its definition. We have adopted that of
Anglada, of Montpellier, quoted and accepted by Trousseau.1 " Contagion
is the transmission of a disease from one person affected with that disease
to one or more persons through the medium of a material cause (principe
materiel), the product of a specific morbid elaboration: this material cause
communicated to an individual in a state of health determines the same
phenomena and symptoms in him as were observed in the individual from
whom the germ proceeded." Understanding what we mean by the term
let us now look at the opinions of the older writers, as well as those of
more recent date, in regard to the mode of propagation of the disease in
question.
Hippocrates makes no reference to the contagion of phthisis, or to the
subject of contagion with regard to any disease, and he is mentioned here
because his views exerted a powerful influence over medical thought until
the early part of the seventeenth century.
The following authorities have recorded their belief in the contagious-
1 Clinical Medicine, Philada., 1873, vol. i. p. 457.
428
Webb, Is Phthisis Pulmonalis Contagious ?
[April
ness of phthisis : Aristotle,1 Galen,2 Riveris,3 R. Morton,4 Baume,5 Cul-
len,6 Heberden,7 E. Darwin,8 C. B. Coventry,9 S. G. Morton,10 Bright and
Addison,11 Dunglison,12 Andral,13 Drake,14 Watson,15 Copland,16 Dick-
son,17 W. Budd,18 Lawson Tait,19 Walshe,20 T. M. Madden,21 and Gueneau
de Mussy ;'22 others holding to the same view, and cited by Dr. Young,23
are F. Hoffmann, T. Reid, Raulin, S. C. Vogel, C. T. SeUe, and A. P.
Wilson.
In order to ascertain the views of some of the prominent authorities of
the present day, the writer addressed letters of inquiry to several gentle-
men, and received the following communications in reply : —
Prof. Alfred Stille states : —
kk I have never seen more than one case in which it appeared to me that
the disease was directly communicated. This was of a mother, between
fifty and sixty, whose husband many years before had died of consumption.
She was herself in excellent, tough health up to the date of her daughter's
last illness, which was with chronic phthisis with cavities. A day before
her death the daughter's breath was very offensive, and the mother, who
was lifting her to change her pillows, inhaled it. She spoke to me of the
foul taste and acrid sensation in her throat produced by the inhalation.
Within a few weeks she began to cough, fell rapidly into consumption, and
died after several months' illness. This is the only case of my own that
appears to bear upon the affirmation of the question.
*• On the other hand, if pulmonary phthisis were often conveyed by con-
tagion, the cases ought to be of daily occurrence, since the disease is the
most frequent of all mortal diseases.
" While C. T. Williams concludes that the disease is not infectious, the
vast experience and sagacity of his father, C. J. B. Williams, led him to
1 Practical and Historical Treatise on Consumptive Diseases. By T. Young, M.D.
London, 1815, p. 121.
2 Paulus iEgineta. Sydenham Society, 1844, vol. i. p. 286.
a Practice of Physic. London, 1668, p. 170.
4 Phthisiologia, or a Treatise of Consumptions. London, 1694, p. 67.
5 Phthisie Pulmonaire. Montpellier, 1789, vol. i. p. 189.
c Practice of Medicine. Edinburgh, 1790, vol. ii. p. 390.
I Commentaries on the History and Cure of Disease. London, 1802, p. 375.
8 Zoonomia. Philada., 1818, vol. i. p. 311.
9 U. S. Med. and Surg. Journ. New York, 1835, vol. i. p. 389.
10 Illustrations of Pulmonary Consumption. Philada., 1837, p. 80.
II Elements of the Practice of Medicine. London, 1839, vol. i. p. 294.
12 Practice of Medicine. Philada., 1844, vol. i. p. 365.
13 Notes to Laennec's Treatise on Auscultation. Edited by Herbert. London, 1S46.
" Principal Diseases of the Interior Yalley of North America. Philada., 1854, p. 915.
15 Principles and Practice of Physic. London, 1857, p. 217.
10 Dictionary of Practical Medicine. New York, 1859, p. 1228.
17 Elements of Medicine. Philada., 1859, p. 625. 18 The Lancet, October, 1867.
19 Amer. Journ. of the Med. Sci., October, 1871.
2U Diseases of the Lungs. London, 1871, p. 452.
21 Dublin Journ. of Med. Sci., vol. xl. p. 33.
22 Brit, and For. Med.-Chir. Rev., April, 1870, p. 529.
23 Practical and Historical Treatise on Consumptive Diseases, London, 1815.
1878.]
Webb, Is Phthisis Pulmonalis Contagious?
429
declare that, ' both reason and experience indicate that a noxious influence
may pass from a patient in advanced consumption to a healthy person in
close communication, and may produce the same disease.' The latter is
my own opinion, and I always feel it my duty to advise that a consump-
tive's bed should be shared by no one."
Prof. J. M. Da Costa writes me : —
u I have met with a number of instances which seemed to prove the con-
tagiousness of phthisis. I am a believer in this, although I admit the great
difficulty of eliminating the law of coincidence in a disease as common as
tubercular phthisis. To mention a few of the instances I have met with :
" I attended a gentleman of tubercular family, and himself suffering
from very slowly developing consumption, which in truth was arrested for
a number of years. He thrice married, and lost his three wives by con-
sumption. The third was a woman of splendid physique, and of a very
healthy, long-lived family. She was the mother of three children ; one is
scrofulous.
" The case of a young woman, 26 years of age, in whose family the
patient assured me there never had been a case of phthisis. She died six-
teen months after her husband, who had had a slowly progressing con-
sumption. She left two children.
" A similar case in a splendid-looking young woman, who most faith-
fully nursed a tubercular husband for nearly two years. She died a year
afterwards of phthisis, beginning apparently with throat and bronchial
irritation. She had, I think, no children.
" A young woman who accompanied her husband to Colorado, where
he died a year ago of a slow consumption. She is tubercular now ; no
case of phthisis has been known in the family except that of her mother's
aunt. One of the children of the young widow died of a scrofulous
affection.
" I might give you many more examples, and I have noticed the fact
that they chiefly happen in women."
J. Solis-Cohen, M.D., writes : —
" I am strongly impressed with the opinion that phthisis can be con-
tracted, that is to say, is communicable rather than contagious in its strict
sense, from frequent continuous contact with the phthisical.
" I attended, during a series of ten years, one son and two daughters,
all young adults, of a gentleman of this city, and subsequently the father
himself, at about the age of fifty years, all of whom died of phthisis under
my care. Two sisters of the father died of phthisis also, under the care
of another practitioner, both married with several children, probably a
dozen or fourteen in all, all of whom are still living, with all the manifes-
tations of phthisis. The father had an aunt, a stout, hale, hearty Eng-
lish woman, who nursed these children when they became sick, often
sleeping with them, and subsequently she contracted acute phthisis and
died under my care within seven weeks, at the age of about sixty-four,
some members of her own family (sisters) surviving her at a more
advanced age, and in good health.
" I have also had several cases in which wife or husband died of phthisis
several years after the death by phthisis of the other party ; in one, and
perhaps more instances, after second marriage, in Avhich I have thought,
the personal history being unphthisical, that the germs of the disease had
been contracted from sleeping with* the diseased individual."
430 Webb, Is Phthisis Pulmonalis Contagious ? [April
Edgar Holden, M.D., of Newark, X. J., writes me that it is —
" My personal observation and belief that persons with consumption
may fatally affect those who are long and closely connected with them."
The authorities who ignore or evade the subject are not many, but
include such names as Trousseau and Niemeyer. This is to be regretted,
as their large experience and opportunities for observation could have
aided materially in settling this important and sadly-neglected mooted
question. Others, again, pass it by, by merely stating, in effect, that there
is a diversity of opinion in regard to the subject. Still less in number are
those who oppose or deny the contagiousness of phthisis; but to this
matter we will return after the perusal of a few more original cases which
have been kindly communicated to the author; and make a reference to
others on record.
Joaquin M. Quilez, M.D., of Cuba, communicates the following case
to the writer, and states that he has been familiar, personally, with both
families, and knows definitely of their antecedents : —
" A gentleman, whose family was subject to hereditary phthisis, mar-
ried a strong, healthy, well-developed young lady, in whose family no
such disposition existed, and in which no case of phthisis could be traced.
A female child, of delicate, though healthy aspect, was the first fruit of
said union ; a second child, of more delicate health, was born, and died in
early childhood. The father, after being sick for some time, died from
his hereditary affection ; and the wife, whose health had begun to decline,
was at last a victim to the same disease."
A. P. Brubaker, M.D., of this city, has kindly furnished the following
case : —
" Mrs. K., aged 33 years, had always enjoyed good health until within
the last six months ; her parents are living and well. Three years ago
she married, her husband coming from a phthisical family ; his mother
and two sisters, it is said, died of consumption. At the time of his mar-
riage one of his sisters had been ill for a year with phthisis. Mrs. K.
attended her constantly for a period of eleven months, when she died. Last
August, nineteen months after the death of her sister-in-law, she was
seized suddenly with what she called 'hives,' followed in the course of a
week with fever, slight cough with expectoration, loss of appetite and
strength, which gradually became worse ; she has lost flesh, and has had
slight hemorrhages, in fact all the train of symptoms characteristic of
phthisis."
J. Simpson, M.D., of this city, has kindly communicated the three fol-
lowing cases : —
" Mrs. C, aged 28 years, of a healthy, long-lived family, was in perfect
health when married. Her husband died in Iowa, of phthisis. Four
months after his death I attended her with slight hemorrhage, dulness was
found at apex of left lung but very limited. She died four months after of
well-marked phthisis. She was one of thirteen children, all of whom, with
the exception of Mrs. C, are living. Her mother died at the age of fifty
with some disease of the liver ; her father is still living. I attended a
grandfather and grandmother, both of whom died when over eighty.
1878.]
Webb, Is Phthisis Pulmonalis Contagious?
431
''Mrs. M., aged 30 years, a strong, healthy Irish woman; she nursed her
husband, who died of phthisis in the early part of 1877. One month
after his degtfh she had a profuse hemorrhage ; on examination a spot of
dulness was found on the anterior part of right lung. She was under my
care four months, the disease sprea'd rapidly, involving the whole of the
right and the apex of the left lung. Mrs. M.'s brothers and sisters are all
living. She had four children, all strong and healthy.
"Mrs. G., of a healthy family ; knew her to be well during her married
life. Her husband, whom she nursed for one year, died of phthisis. A
month after his death she showed symptoms of bad health, with slight
cough ; examination revealed disease of anterior portion of apex of the left
long. She died in eighteen months of phthisis."
An examination of medical literature shows that cases of phthisis by
contagion have also been recorded by C. B. Coventry,1 S. G. Morton,2
Drake,3 M. J. Guerin,* Condie,5 Tait,6 Bowditch,7 C. W. Steyens,8 and
Prof. A. Flint.9
The author who opposes the contagiousness of phthisis with the greatest
force is Dr. Henry Mac Cormac, of Dublin, Ireland. In his ingenious
and interesting work,10 he states that " Consumption is not communicated
by any infection or contagion whatever, any more than a fractured limb
is so communicated." (p. 109.) Yet he declares, in the most vehement
manner, that phthisis is engendered and propagated by pre-breathed air.
TVe will select one sentence, and in doing so it will be, in a manner,
giving the text of the whole book. " If we poison the atmosphere with
the products of respiration, the atmosphere so empoisoned poisons us in
turn." (p. 127.) He thus inadvertently makes himself one of the strong-
est advocates of the contagiousness of phthisis, as he teaches more than he
really meant at the time of writing his book ; for it is well known that
the effete matter thrown off from the' lungs of a person who has phthisis,
especially in the advanced stages of the disease, contains, besides the usual
effete material, pus and muco-pus ; in fact, all the constituents of tubercu-
lous matter. Now, is it not reasonable, if pre-breathed air will produce
phthisis, that air loaded with such material as the above would be more
likely to cause it, for herein reside the " material cause" ?
If tubercle can be communicated by inoculation, as maintained by
Villemin,11 TTilson Fox,12 Marcet,13 and others, it proves the existence of a
I U. S. Med. and Surg. Journ. New York, 1835, p. 392.
" Illustrations of Pulmonary Consumption. Philada., 1837, p. 80.
3 Principal Dis. of the Int. Yal. of X. A. Philada., 1851, p. 915.
4 Brit, and For. Med. Rev., vol. ix. p. 310.
1 Amer. Journ. of the Med. Sci., July, 1871. 6 Ibid., Oct. 1871.
7 Bost. Med. and Surg-. Journ., 1861, p. 329. 8 Ibid., 1875, p. 119.
9 On Phthisis. Philada., 1875, p. 119.
10 On Consumption. London. 1865.
II Etudes sur La Tubereulose. Paris, 186S.
11 The Artificial Production of Tubercle in the Lower Animals. London, 1868.
13 Medico-Chirurgical Transactions, 1867.
432
"Webb, Is Phthisis Pulmonalis Contagious?
[April
specific morbific matter, and this fact alone would give great support to
the disease being propagated by contagion.
The preference that tubercle manifests for the lungs in tuberculosis is in
harmony with the law of choice or affinity which belongs to zymotic dis-
eases generally. No one doubts the fact of the existence of typhoid poison
in the blood before it is made manifest by a lesion in the glands of Peyer.
Nor can we doubt the existence of a like contaminating influence in the
blood before we note the peculiar pathological condition known as pulmo-
nary tuberculosis. The tubercle, still preserving the harmony of the
general law, is nothing more than the culmination of the process of the
disease, the softening and breaking down of which is an inherent weak-
ness of the materies morbi, and, being a foreign matter, the lungs rebel
against its presence, and make an effort to cast it off. Thus, then, Ave
conclude that the blood is attacked primarily, the disease having a period
of incubation or pre-tubercular stage ; and that the individual is in a
pathological condition prior to the development of tubercle.
The writer of the present article agrees with Dr. P. M. Latham.1
that " Pulmonary consumption is no more than a fragment of a great
constitutional malady, which it would be vain to think of measuring by
the stethoscope, and which it belongs to a higher discipline than any mere
skill in auscultation rightly to comprehend." This accords with a number
of diseases belonging to the zymotic group ; with diphtheria, where we may
only have the sequelae present, the faucial mucous membrane never being
attacked or affected ; or again with scarlet fever, without or with but
merely perceptible eruption, the sequeke being most marked; or further
still, as we see in some epidemics of smallpox, with cases modified by
vaccination without eruption, and know the case symptomatically. Or
let us take the disease phthisis itself, some cases, acute phthisis, may run
their course in less than three weeks, the disease explodes, as it were, and
the lungs are overwhelmed with miliary tubercles ; other cases, chronic
phthisis, may last twenty years, the disease advancing in a very stealthy
manner. All these examples show difference in degree of each individual
" material cause." And Pollock3 states : " The examination of the aged
proves that consumption may exist independently of tubercular develop-
ment, contrary to the opinions of Louis and Laennec."
It will be noticed that all the original cases in this article are females ;
this very fact not only proves the correctness of the statement of that
distinguished authority, Prof. Da Costa, " that they chiefly happen in
women," but also proves that phthisis is a contagious disease ; the writer
firmly believes that if it were possible for a correct clinical history to be
obtained of the females who died of phthisis in Philadelphia in the ten
1 Clinical Lectures, Bell's Journal. Philada., 1837, vol. i. p. 133.
3 Elements of Prognosis in Consumption. London, 1865, p. 135.
1878.]
Webb, Is Phthisis Pulmonalis Contagious?
433
years 1867-1876 (50t9q per cent, of the whole number), it would be found
that more than the excess of 1 f per cent, of females could be proved to be
due to contagion. The reason that women are attacked more often with
the disease is readily enough explained by the fact that theirs is the office
of ministering angels in the sick room. There are but few physicians who
have not known of instances where women have nursed for from six to
twelve months in lingering diseases other than phthisis, who were " run
down" in health, through loss of sleep, appetite, strength, and became
anaemic, etc., from constant attention and anxiety, and yet did not con-
tract phthisis from these causes. It is not to be understood by this that
we hold that every woman or man who nurses a case of phthisis will
contract the disease, but only that it does occur sufficiently often for the
physician to recognize the fact. If there be an hereditary taint — the
powder — in the nurse, and if she take charge of a phthisical patient — the
spark — there is no doubt that the chances are against her safety ; whereas,
if she do not expose herself to its further influence, she may live a long
life and finally die of some other disease. The writer affirms that there
is more danger to be dreaded from nursing the phthisical than there is
from nursing cases of typhoid fever; in the latter the "material cause"
resides in the excreta, and by cleanliness the contagious element is
destroyed and removed ; not so in phthisis, for in that disease the
" material cause" resides in the effete matter constantly being thrown off
from the lungs of the stricken individual, more especially in the advanced
stages of the disease.
The late Dr. Cotton,1 of Brompton, may have said truly that " a resi-
dence in the consumptive hospital, and long-continued working in its
wards, is a very good way, indeed, not to catch the disease" as there is a
great difference between the nursing of the phthisical in hospital and
in private practice ; in the former there is one skilled nurse to probably a
dozen or more patients, and they occupy their own apartments after being
on duty a portion of the twenty-four hours, and hygiene and regimen are.
carried out to the highest point of excellence known. Xot so in the lat-
ter, for here all patients have their own nurses, either some member of
the family or friend, who are unskilled, and, as a rule, the circumstances
under which they perform their office are such as to render them more
liable to fall victims to contagion.
That there must be something more than inheritance to keep up the
enormous mortality of this disease, is quite evident from the investigations
that have been made by some of the most competent observers. Dr. E.
Darwin Hudson, Jr.,2 in an elaborate monograph on phthisis, states that
" Dr. Cotton analyzed one thousand cases at the Brompton Hospital, and
could prove hereditary taint in but three hundred and sixty-seven. Scott
1 British Medical Journal, 1872, vol. ii. p. 239.
2 Transactions of the New York Academy of Medicine, 1876, p. 149.
434 Wendt, Chronic Muscular Symptoms after Trichinosis. [April
Allison's observations at the same institution [out of six hundred and
three cases he has only seen the influence manifested in nineteen eases]1
were equally negative. Walshe, by careful inquiry among the phthisical,
concludes that not over 26 per cent, have had parents affected with phthisis.
M. Pidoux says not over 25 per cent, of those born of consumptive parents
themselves become so." The remaining 70 or 75 per cent, must be due
to other causes than inheritance, and among these I believe contagion to
hold a prominent place.
That phthisis is a contagious disease, and therefore belongs to the
zymotic group, the evidence and proof, as herein presented, is, the -writer
believes, decisive and irrefragable.
633 North Sixteenth Street.
Article XV.
Chronic Muscular Symptoms after Trichinosis. By Edmund C.
Wendt, M.D., of New York.
In 1872 a number of persons, all members of one family, suddenly fell
ill with symptoms pointing to some common cause, supposed at first to have
been a noxious substance ingested with some article of food. A series of
chance suggestions, among other things, called attention to a ham, some
slices of which had been eaten raw, several days previous to the first
appearance of illness. Upon examination this ham was found to contain
large numbers of trichinae, scattered through its fibres, all in a state of
advanced encystation. The diagnosis was thus established beyond doubt,
and these cases afforded an admirable opportunity of studying the great
variety of symptoms resulting from trichinous invasion. Accordingly a
careful surveillance of the patients was constantly pursued, and all morbid
manifestations were diligently observed. A detailed account of the results
of this supervision is here uncalled for, but a succinct reference to the most
striking symptoms seems indicated.
Briefly then, I may say that the illness was initiated by malaise, nausea
(in one case vomiting), loss of appetite, and diarrhoea. Thirst became
considerably increased, and fever was developed. In addition to these gas-
tric and febrile symptoms, and after they had lasted about five days, acute
muscular pain commenced to be felt. This rapidly increased in severity,
and I now observed stiffness and rigidity of the limbs, with a marked
indisposition to motion and extreme reluctance to be touched. There was
also a certain amount of dyspnoea. In the case of Miss N. B., these
1 Transactions of the New York State Medical Society, 1871, p. 172.
1878.] Wendt, Chronic Muscular Symptoms after Trichinosis. 435
appearances were intensified by excessive raucedo, oedema extending over
the face and neck, accompanied by redness, heat, and pain principally
about the orbital region, with puffiness of the eyelids, tumefaction of the
limbs, especially prominent in the lower extremities. (The examination
of the urine proved it to contain no albumen.)
In one case a profuse diarrhoea remained for nearly two months un-
checked by a generous administration of the usual remedies. Gradually,
however, these symptoms abated, the rheumatismoid pains became less
severe, the alvine evacuations diminished in frequency, and with the re-
appearance of appetite the fever subsided. The sickness had lasted about a
month ; but the final extinction of pain was prolonged several weeks, and
a noticeable weakness remained still longer.
It is evident, therefore, that these patients presented no peculiarity to
distinguish their cases from similarly typical ones, and further that the
present disease must be grouped under the head of moderately severe
attacks. In the course taken by this illness, I noticed no departure from
the regular series of successive symptoms, such as established by the best
authors.
Before proceeding to the communication of what I believe to be so far
unusual as to merit publicity, I will specify how I came to discover this
irregularity. Going abroad shortly after the above occurrences had tran-
spired, I lost sight of my interesting cases, and would probably have for-
gotten their painfully noteworthy visitation, had not my own person acted
the part of a disagreeable reminder. In this connection it behooves me to
state that I have myself undergone all the agonizing torture following and
resulting from consumption of trichinous meat. Moreover that ever since
my personal intimacy with the parasitical tormentors, I have been sub-
jected to frequent attacks of what I formerly supposed might be muscular
rheumatism, but have latterly concluded must be directly connected with
trichinosis. The considerations that have convinced me of the accuracy
of this view are numerous and weighty, so that at present I venture to
assert that trichinous invasion bears an undeniable causal relation to cer-
tain phenomena and morbid symptoms, hitherto not clearly demonstrated.
On my return to this country after an absence of nearly five years, I
made inquiry as to the condition of health enjoyed by my former patients,
and to my surprise I was informed that they were all troubled with occa-
sional attacks of rheumatism. Upon further examination I ascertained
that their " rheumatic trouble" dated from the year of the trichinous in-
fection, and that prior to that time similar pains had never been expe-
rienced by any one of their family. This in itself may appear neither
strange nor unusual, as records of " rheumatism" occurring in all the mem-
bers of one family have not unfrequently been made. But when I make
use of the term rheumatism, it is simply borrowing the expression em-
ployed by my patients. A careful study of their symptoms reveals some
436 Wendt, Clironic Muscular Symptoms after Trichinosis. [April
unmistakable deviations from the morbid aspects of a typical muscular
rheumatism.
Resuming then the consideration of these symptoms, I may describe
the most prominent one as consisting particularly in a certain amount of
painfulness. Located exclusively in various groups of muscles, this pain-
fulness is at times heightened so as to render the parts exquisitely sensi-
tive. In this deplorable condition, even very moderate pressure is produc-
tive of severe suffering, and the patient anxiously seeks to avoid all contact
of the aching regions with the outer world. Happily this state of affairs is of
comparatively short duration, rarely lasting over five or six days. When
it has disappeared it is frequently superseded by long intervals free from
pain. In this respect, I find no dependency on changes of weather or
climate ; and equally at all seasons of the year there exists a marked tend-
ency to acquire " painful spots" or " sore places." Sometimes, and espe-
cially after prolonged muscular exertion, the strained parts will suddenly
begin to ache, and occasion intense dolor. Quickly as it came the pain
may then vanish and leave no trace behind it. At times, however, it will
decline only gradually, lingering here and there, and imperceptibly dying
out. (The latter course is less frequently taken than the former.) Then
again an extremely annoying sensation may slowly develop itself. This,
also seated in the muscles, is evinced as an irksome tension, difficult of
description. Still it may be characterized sufficiently by its manifest
resemblance to the disagreeable feeling of the young, popularly called
" growing pains." My attention was directed to this point by a sponta-
neous statement on the part of my patients, after I had previously arrived
at a similar conclusion regarding my own personal experience of this
sensation. That such growing pains should occur in adults seemed para-
doxical, and accordingly " rheumatism" was again resorted to as an
appropriately extensive appellation, including in the wide scope of its
significance all painful sensations of a dubious kind.
Now and then there exists only a certain tenderness to touch, and this
may continue unchanged in its peculiarity for weeks at a time ; occasion-
ally shooting pains will arise and extend over large muscular regions, and
again at other times the pain (generally felt in a definite quarter) may be
difficult to localize, rapidly shifting from one place to another, and attack-
ing in succession many different points. Thus, for example, a dull, heavy
sensation around the fleshy insertion of the quadriceps may have existed
for some time, when suddenly violent twinges upwards to the hip will be
felt, or a pungent pain in the gastrocnemius abruptly extends downwards
to the foot. From the sterno-cleido-mastoid to the pectoral or deltoid re-
gion, and thence to the arm and forearm, from the neck down the back to
the gluteal region aud similarly elsewhere, this aching frequently presents
itself. Still the organic function of the muscles is not permanently im-
paired ; but, since any violent exertion may be followed by such harassing
1878.] Wendt, Chronic Muscular Symptoms after Trichinosis. 437
results, there exists an uncontrollable reluctance on the part of the patients
to engage in active exercise, and this leads to a certain deficiency of mus-
cular action. It is not surprising, therefore, to find the muscles rather
flabby and wanting that elastic rigor which characterizes the healthy, nor-
mally active organs.
A doughy condition of the muscles, such as exists in the present cases.,
may not be an exceptional occurrence long after the acute symptoms of
trichinosis have ceased to torment patients, but similar observations have
scarcely ever been recorded. Indeed, if I except two cases, in some points
not unlike those engaging our attention, I may safely assert that the nu-
merous publications bearing on this subject, elaborately prepared as many
of them undoubtedly are, contain no mention of analogous symptoms. A
condensed extract of the important points in these cases I insert here. The
first of the two is interesting in many respects, and has been extensively
commented upon by Virchow1 and other pathologists.
'; A German lady, Miss Th. X., emigrated to this country, where in 1856 she
(as also her mother and brother) was dangerously ill with the symptoms of
trichinosis. Since that time she complained of decided weakness, mainly in her
fingers. Manual operations became difficult and fatiguing. She had formerly
been quite a virtuoso on the piano, and had always possessed great nimbleness
and dexterity in the performance of needlework. These accomplishments she
had lost and subsequently never regained. In 1864, she died in the hospital of
Altona (Germany), having previously undergone operation for cancer of the
breast. The autopsy revealed large numbers of encysted trichinae in her mus-
cles. The capsules were cretified, but the parasites still alive and capable of
growth and reproduction. The second case2 is that of a butcher, well developed,
strong, and healthy, who retained after trichinosis an excessive muscular weak-
ness, which made him unfit for military service. The former facility for perform-
ing all actions requiring muscular power had lastingly disappeared, and his original
force of body had so far diminished that walking was no longer an easy under-
taking."
Similar observations are not recorded elsewhere. The large majority
of authors on trichinosis claim to have seen either complete recovery, which
would seem to be the rule, or death, apparently the exception. The fatal
termination may result from various acute inflammatory processes engen-
dered by the irritating presence of the worms. Secondary degenerations
and numerous complications brought on in this way may likewise be a more
remote cause of death. Thus, for example, cases of extreme emaciation
with complete exhaustion of all vital energy are not uncommonly found in
the literature of this disease. But that the trichina?, having undergone en-
cystation, may still be the source of pain and suffering, that for years and
years their presence in the muscles of the afflicted individuals may give rise
to disagreeable if not serious symptoms is, to my knowledge, nowhere inti-
mated. Yet such would appear to be the case when we consider the facts
before us.
1 Virchow, die Lehre von dem Trichinen, Berlin, 1866, p. 39. Also Groth, in Vir-
chovr's Archiv, vol. 29, 1864, p. 604 ; and Timm, ibid. vol. 30, p. 447.
2 Rupprecht, Rundblick auf die Trichinen literatur. Vienna, 1866.
438 Wendt, Chronic Muscular Symptoms after Trichinosis. [April
I think, moreover, that this is by no means extraordinary. On the
contrary, it seems marvellous that similar consequences should never have
been anticipated. Are the symptoms described above not precisely what
might be expected as the necessary result of a multitude of foreign bodies
occupying the muscular system ? In order to see our way clearly, let us
call to mind what takes place when the trichinae pierce the intestinal walls,
and, having penetrated different tissues and organs, finally arrive at their
ultimate destination — the muscles.
We know that as soon as the parasites have found a voluntary muscle,
they perforate its elastic sheath, and apparently despising a permanent
occupation of the interstitial connective tissue, enter the fleshy fibril itself.
There they continue their migration until some obstacle is interposed in
their way. The greedy worms consume the contractile substance of the
fibril ; thus only the sarcolemma is spared. It is clear that an acute my-
ositis must follow. About this time the patients complain most of excru-
ciating muscular pain, and the fever is at its maximum height. The
microscope now shows a complete transformation of the affected fasciculi.
The transverse and longitudinal striae no longer appear, the sarcolemma
contains a molecular mass accumulated around nuclei, and these have be-
come considerably increased in number.
When the worm has chosen its resting-place, and coils itself up, a reac-
tionary inflammation of the surrounding fibres takes place. The sarco-
lemma in the immediate proximity to the parasite becomes thickened,
which action initiates the formation of a capsule. The latter, some time
after its completion, undergoes the well-known phenomenal change of creti-
fication, so that the whole cyst becomes a chalky mass inclosing living
parasites. Subsequently, even the worm may be transformed into calca-
reous matter, but the exact time when this ultimate result is accomplished
has not been hitherto ascertained. Middeldorpf states that he has ob-
served living worms after a period of encystation in one case of twenty-
four years.
Here undoubtedly the muscles still contain hard chalky particles, scat-
tered through their fibres, and the harpoon will easily demonstrate this fact.
Now even an ct priori consideration of this state would make it appear
strange that the continual presence of innumerable foreign bodies in the
muscles should be unattended by any perceptible modification of functional
activity or normal sensation. No doubt the individual corpuscle is too
small to cause appreciable disorder, but the accumulated effect of the sum
of all these granules must be expected to produce discernible changes.
Grains of sand disseminated through organs endowed with vital contraction,
and supplied by sensory nerves, would presumably give rise to peculiar
sensations. In face of these considerations, any positive observation of
such effects must more than counterbalance the negative statements of
authors.
1878.]
At lee, Wound of the Trachea,.
439
In his Traite des Entozoaires (Paris, 1878), Davaine devotes thirty-six
pages to the discussion of trichinosis and its well-marked morbid anatomy.
On page 759, he says, " les trichines ne causent done des accidents que
par leur presence dans l'intestin et par- lenr invasion dans les chairs. Ces
accidents sont essentiellement passagers. Lorsque les parasites se sont
loges dans les fibres musculaires et qu'ils sont separes de 1'organisme de leur
hofce par un kyste, ils y restent indefmiment inofFensifs." This enuncia-
tion might lead one to suppose that there exists some specific virus which
makes the trichinae particularly offensive ; and that as soon as they become
" separated from the organism of their host by a cyst," no further symp-
toms are experienced, and the animals imprisoned within their capsules
cease to be an object of danger or even pain.
I admit that the greatest danger is over as soon as encystation com-
mences. But, on the other hand, I hold that the capsules are liable and
likely to cause painful symptoms for a period of indefinite length. Of
course, we are at liberty to say that it is not the parasite, but rather its
calcareous envelope, which brings about the abnormal sensations explained
above.
The condition described is one of chronic myositis with acute exacerba-
tions after trichinosis. This definition seems in every way sufficient and
satisfactory, accounting for all the symptoms in a rational way, and remov-
ing the questionable disease from the field of obscure conjecture to the safe
grounds of morbid anatomy and scientific pathology. It no longer appears
surprising that the painfulness should be confined to the muscles ; that it
should show a marked predilection for those very regions which, in the
primary acute attack, had suffered most (i. e. the flexors of the extremities) ;
that its coming and going should be controlled by no regularity ; and that
when it has disappeared, weeks and months may elapse before it returns.
Article XVI.
Wound or the Trachea ; Bloody Expectoration and Emphysema
following ; Tracheotomy not Performed ; Recovery. Communi-
cated, with Remarks, by Walter F. Atlee, 31.1)., of Philadelphia.
In the number of this Journal for January, 1858, a case, supposed to
have been Rupture of the Trachea, is reported, that occurred in the prac-
tice of my brother, Dr. J. L. Atlee, Jr., of Lancaster. Two quite similar
cases, in one of them the larynx being the seat of the injury, which were
all that could be found recorded of this rare injury of the air-passages,
were also related in the communication, and the opinion was given that
when the true nature of the accident was ascertained, and emphysema be-
came extensive, tracheotomy should be at once resorted to.
440 A t l e e , Wound of the Trachea. [April
Several years afterwards (April, I860), on the occasion of a case that
occurred in his own practice in the Pennsylvania Hospital, Dr. WflL Hunt
contributed to this Journal a most valuable article on injuries of this kind,
entitled " On Fractures of the Larynx and Ruptures of the Trachea." In-
cluding his own, Dr. Hunt collected as many as twenty-eight perfectly
authentic cases, and with this quite considerable experience this distin-
guished surgeon wrote as follows : "I think our list shows that active and
prompt treatment by laryngotomy or tracheotomy gives the only hope of
success when the emphysema and bloody expectoration show that the
mucous membrane has been lacerated by the broken fragments
If then, after getting the history of a case, we have bloody expectoration
and emphysema accompanying the other symptoms, an operation should
at once be performed, for iveJiave obtained no record of such a case get-
ting tv ell without it."
Since Dr. Hunt's article there have been several contributions about
these injuries in this Journal. In the number for January, 18G7,is a case
where death followed a wound made by a fragment of shell that passed
through the floor of the mouth, producing a severe compound fracture of
the inferior maxilla, and obliquely over the neck to the middle of the
right clavicle, which was broken (compound fracture). Emphysema, dif-
ficulty of breathing, and extinction of the voice followed, and death took
place on the sixth day. At the autopsy, to the surprise of all, the cavity
of the chest was found uninjured ; but the right wing of the thyroid car-
tilage was found fractured.
In the following number (April, 1867) is a case that is particularly
interesting from its having been presented and commented upon by so
high an authority as Dr. F. H. Hamilton. The patient died two hours
and a half after the receipt of a kick over the larynx. The cricoid and
thyroid were both fractured, and there was extensive infiltration of blood
underneath the laryngeal mucous membrane, filling the larynx. Dr.
Hamilton says that it is very apparent that an operation might have saved
the patient's life. Fie also refers to another case of fracture of the cricoid
and thyroid cartilages, on which he operated, with entire relief to the
symptoms of suffocation , though the patient's life was not saved, probably
on account of injury inflicted to the lungs before the operation in violent
struggles for breath.
In April, 1868, a case (from the Gazette des Hopitaux) of traumatic
fracture of the larynx, caused by pressure with the hands in a quarrel, is
related by Dr. Fredot. The patient did well until the third day, when
he suddenly fell dead. The sudden death seemed to have arisen from the
displacement of one of the fragments of the cricoid and the corresponding
arytenoid, which, riding on the other, completely obstructed the passage
of air. Having noted the principal facts of the few cases that are on
record, Dr. Fredot observes that they may be divided into two categories
1878.]
A t l e e , AVound of the Trachea.
441
as regards treatment. " In the first, the affection is so slight as hardly to
attract the patient's attention, and then silence and rest suffice.1 In the
more complicated cases the injury may induce death before any treatment
can be put into force ; or they may be accompanied by dyspnoea, cyanosis,
convulsions, aphonia, tumefaction, or deformity of the neck, emphysema,
etc. ; and as death may be produced at any moment by displacement of
the fragments, or by oedema of the glottis, the surgeon should, even when
the symptoms are not very urgent, at once practise catheterism of the
larynx, or, better still, tracheotomy. Had this been done in the case re-
lated above, the patient's life would probably have been saved."
In the number for July, 1869, is a case from the Dublin Quarterly
Journal for May. The subject was a female, who had received a kick
in the throat from her husband, dyspnoea came on soon afterwards, which
increased rapidly in intensity, so that she died before Mr. Win. Stokes,
Jun., who had been sent for to perform tracheotomy, could reach her.
At the autopsy, a double fracture of the cricoid cartilage was found, with
displacement inwards of the left fragment, and displacement of the aryte-
noid on the right side. There was no laceration of the mucous membrane
of the larynx, and consequently no emphysema. The glottis was almost
completely occluded by blood effused beneath the mucous membrane,
especially under the aryteno-epiglottidean folds, and in the ventricles.
All the soft tissues about the larynx outside were profusely infiltrated
with blood, although no laceration of a large vessel could be determined.
Mr. Stokes relates a similar case that occurred in the practice of Mai-
sonneuve, where the patient recovered after tracheotomy ; being obliged,,
however, ever after to wear a tube, on account of contraction of the larynx-
He says that this successful result makes it an unceasing source of regret
that he did not arrive at the hospital sufficiently early to perform the ope-
ration, and in all probability save the life of the patient.
The last case recorded in the Journal is in the number for October,
1871, taken from the Centralblatt f. d. Med. Wissenschaften. The subject
was a soldier, who was kicked in the anterior part of the neck, and who
afterwards had cough, tracheal rales, but no bloody sputa, with tolerably
extensive emphysema of the neck. From these symptoms the diagnosis
was a transverse rupture of the trachea. This patient appears to have
recovered without an operation, but the account given is not quite satis-
factory. It is there stated that Gurlt has found recorded cases in which
there was a solution of continuity from accident in the walls of the tra-
chea ; in five the wound was accompanied with fracture of the thyroid
1 It may be followed, however, after a long time by local inflammation and abscess.
In one case, which I witnessed, an abscess forming twenty months after the injury.
See Xelaton's Clinical Surgery, from Notes taken by Walter F. Atlee, M.D., Phila.,
1855, p. 122.
No. CL — April 1878. 29
442
Atlee, Wound of the Trachea.
[April
cartilage. In one only of those cases was there a favourable termination,
and then only after a resort to tracheotomy.
I have called attention to these cases for several reasons ; they show,
I think, that in severe injuries to the larynx tracheotomy should be re-
sorted to without delay ; that death is caused by obstruction from effusion
of blood under the laryngeal mucous membrane, or by displacement of the
injured laryngeal cartilages ; and they do not show, as writers on surgery
often say, that emphysema is a dangerous complication, calling for trache-
otomy, perhaps, not even for scarifications.
Wounds of the trachea, therefore, so far as the peculiar threatening to life
is concerned, and the urgent necessity of surgical interference, must differ
from those of the larynx. They have certain things in common, but not
enough to allow them to be treated together, as is generally done in works
on surgical practice. They should be separated, as well as those affecting
the bladder and penis.
Emphysema is a phenomenon that may occur in any case where there
is wound of the air-passages below the glottis. When there is not paral-
lelism between the opening in the air-passages and that in the skin, the
air expelled in expiration is pushed into the cellular tissue. When the
larynx is wounded, it is said that the glottis may be so constricted by
emphysema extending through the submucous tissue as to cause suffoca-
tion. (See Holmes, System of Surgery 2d edit., vol. ii. p. 443.) This,
of course, would not occur in a wound of the trachea. It lias been said
that the action of the phrenic nerves may be so interfered with by emphy-
sema as to lead to a fatal result. This I cannot credit. That first-rate
authority, Hamilton, when treating of fractures of the ribs, says : u Em-
physema is present in a pretty large proportion of cases. It has been
observed by me in ten out of eighteen cases." " In one case it extended
over nearly the wrhole body." " The emphysema generally demands no
special attention, since it is usually too limited to occasion inconvenience,
and when more extensive it generally disappears spontaneously after a few
days, or a few weeks at most. The advice given by some surgeons that
we ought in these cases to cut down to the pleural cavity, so as to allow
the air to escape freely through the incision, seems thus far to have rested
its reputation upon a more than doubtful theory rather than upon any tes-
timony of experience." From the cases referred to by Hamilton, it would
appear that, when incisions were made to relieve the emphysema, the pa-
tient died, and that when the patient was let alone, although the emphy-
sema was so extensive as to extend over the whole body, and even to close
the eyes, the patient got well. (Practical Treatise, etc., pp. 176-7-8.)
The case calling for these remarks, which, although lengthy, cannot be
judged unnecessary by any one who should consult special or general
works on surgery for assistance under similar circumstances, is as fol-
lows : —
1878.]
Atlee, Wound of the Trachea.
443
Lncien P., a healthy, lively boy, seven and a half years of age, while
amusing himself with a pair of scissors, pointed in both blades, found them
working rather stiffly, and reaching to seize an oil-can, he tripped and fell
in such a. way that the points of the closed blades punctured the neck over
the second ring of the trachea. The wound was longitudinal, three-tenths
of an inch in length, and five-tenths in depth. His father, who saw him
a moment afterwards, described him as " covered with blood, oozing out
of his throat." He sent at once for the nearest physician, and carrying
the boy to the bath-room, washed the wound, and applied at once a piece
of folded linen soaked in phenol-sodic to stop the hemorrhage, and tried
to pacify the child as well as he could ; for he noticed that while crying
some air escaped from the wound with the blood. The phenol stopped the
bleeding almost instantly, and the child became more quiet. For a short
time he spat up some blood, but this only lasted for a few minutes. When
Dr. Porter saw the patient, very soon after the injury, he found him with
the symptoms of severe shock, with some slight emphysema near the
wound, but quiet and breathing regularly. This was the condition of
things an hour or more afterwards when I reached the house.
In the course of the following night, the poor boy, while vomiting to
relieve his stomach of undigested food, imprudently given, forced the air
in a few moments into the cellular tissue of the face, neck, and front of
the chest, to the utmost possible extent. As the weather was suitable for
such an observation, being damp and cold, so that the breath could be seen,
I was much struck by seeing with what violence the air is expelled from
the chest, in the expiratory effort made after strong and repeated strain-
ings to empty the stomach. When called this time, I took with me the
necessary instruments for the performance of tracheotomy ; but after some
hesitation, and with the concurrence in opinion of Dr. Porter and Dr.
Hodge, whom it was my good fortune to meet in consultation, it was con-
cluded to be the best to wait, using at the same time means to keep the
patient very quiet, and to prevent any commotion of the stomach. Full
doses of chloral hydrate, with bromide of potassium, were given at regular
intervals to assist in this, so that for a couple of days the child was almost
constantly asleep. The wound healed quickly, the emphysema gradually
disappeared, and, after a confinement of ten days, to guard against inflam-
mation of the air-passages, the patient was allowed to go about as usual.
While looking over works on Surgery, I came upon the following case
in Ambrose Pare ((Euvres Completes, par Malgaigne, liv. 8, chap. xxx).
In his chapter on Wounds of the Neck and Throat, he relates the follow-
ing history (as worthy of being left to young surgeons) ! It is, in the
original, one of the most charming cases I know of in surgical literature.
' * In the year 1574, on the first day of May, Franqois Brege, pastry-cook of
my Lord of Guise, was wounded in the neck by the blow of a sword, at Jeinville,
cutting a part of the windpipe and one of the jugular veins, from which issued a
great flow of blood, and from the windpipe a chiflement. The wound was sewed,
and astringent remedies applied ; and soon afterward the wind that went forth
from the wound entered into the fleshy skin and the space of the muscles, not only
of the neck, but also of the whole body (like a sheep that has been inflated to be
skinned), and he could not articulate in the least. The face was so swollen that not
any appearance of a nose could be seen nor eyes. Seeing the symptoms, all the
assistants concluded that Brege had more need of a priest than a physician, and
consequently extreme unction was administered to him. On the next day my
Lord de Guise commanded master John Lejeune, his physician-in-ordinary, accom-
444 Atkinson, Contagious Vulvitis in Children. [April
panied by Mr. Bugo, celebrated physician of Madame, the Dowager of Guise, to-
gether with James Girardin, master Barbier, the physician in the town of Jein-
ville, who having seen him, the said physician was of the advice to leave him,
despairing of any remedy, and not finding the pulse of the arteries beating in any
manner on account of the great swelling of the skin. Lejeune not wishing to
leave him without having tried something, and like a bold operator, through^ the
good experience he had from a quick mind, was of the opinion to trv an extreme
remedy, which was to make several scarifications pretty deep by which the blood
and the ventosities were permitted to escape. At last the pastry-cook recovered
his speech and sight and was shortly afterward entirely cured* by the grace of
God, and is now living and doing service to my Lord of Guise in his office of
pastry-cook."
Article XVII.
Report of Six Cases of Contagious Vulvitis in Children.
By I. E. Atkinson, M.D., of Baltimore.
Purulent discharges from the external genitals of female children are
sufficiently common to fall under the notice of every practitioner. Almost
all of these cases occur in children who may be recognized as scrofulous or
tuberculous. There are cases, however, where the vulval mucous mem-
brane becomes inflamed in consequence of irritation from the presence of
ascarides in the rectum, or, as has been claimed, from dentition, or from
scarlatina, or possibly from other zymotic affections ; finally, irritation
directly applied may occasion the inflammation.
The importance of a correct etiological understanding of such cases
has long been recognized by medical writers, on account of the relation
they are apt to have with questions of medical jurisprudence. While it is
desirable that the profession should be informed as to the occurrence of
this inflammation in consequence of systemic conditions and of reflex and
simple direct irritation, it becomes all the more essential to entertain cor-
rect ideas regarding those cases where the simultaneous existence of the
disease in several individuals dwelling together makes it certain that
there is a common cause ; almost certain that they are due to a specific
contagious principle. This consideration has induced me to report the
following cases of vulvitis occurring in a charitable institution of this city,
of which I have partial medical control.
Case I — Mary N., aged twelve years, was first seen by me June 5th,
1876. She had never menstruated; was of good physique and free from
appearance of scrofulous taint. The notice of the attendant was attracted
by her awkward gait. When questioned, she complained of having been
unwell for several days with pain in the lower portion of her abdomen,
and much distress in micturition. She had a free discharge of thick, yel-
low, sticky pus from her vulva, which was of a raspberry-red colour, and
cedematous about the labia majora. The vaginal orifice was minute.
Case II — Mary C, eight years of age, small and frail, but healthy
1878.]
Atkinson, Contagious Vulvitis in Children.
445
since her residence in the institution, was also first seen by me June 5th.
She had no pain upon micturition, but there was tenderness and deep
redness about the vulva, with, however, not very much discharge. She
said she had been thus affected for several days before coming into the
infirmary.
Case III. — Ida McM., five years old, of small and delicate frame ; was
in the infirmary June 1st, with diarrhoea. She was discovered to have
vulvitis June 5th. She had not slept in the. same room with the other
girls for. at least six nights. There was no pain upon micturition, but the
discharge was more copious than in either of the other children.
Case IV Laura W., aged five years, had, June 6th, a vulvitis of
considerable intensity. She has a stiff hip joint from coxalgia.
Case V Hattie S. had, June 8th, a free vulvo-vaginal discharge,
with considerable cedema of the labia, and an erythematous condition of
the surrounding integument.
Case VI Eva H., a stout, hearty girl, had a moderately intense vul-
vitis, with slight purulent discharge and deeply reddened mucous mem-
brane. Pressure caused a small quantity of pus to flow from the vaginal
orifice.
The course of the disease in these children was not in any way remark-
able. Upon admission they all looked pale and badly. In all of them
there was slight but steady elevation of temperature, varying from 99° F.
to 101.5° F., the latter figure being reached by only one of the girls, who
then had some anorexia and vomiting, and whose vulval mucous mem-
brane was partially stripped of its epithelium. One child, Eva K., was
discharged cured June 23d, but the others were under constant attention
until August 1st, when they were allowed to return to their dormitory.
As will be observed, the treatment of these cases proved very tedious.
When first coming under observation, they were ordered cod-liver oil and
the citrate of iron and quinia, in full doses, internally; and as external
applications washes were used, each for more or less protracted periods,
and in regular succession, consisting of solutions of the potassio-tartrate of
iron, of alum, of carbolic acid, of hyposulphite of soda, and of acetate of
lead, accompanied or followed by salicylic acid and oxide of zinc in pow-
der. Decided improvement was not obtained until a solution of nitrate of
silver, from one-half to one-third of a grain to the ounce of distilled water,
was employed. From this time the improvement was rapid.
Immediately upon the discovery of the disease in the first of these
children, a rigid investigation was made throughout the institution, with
the result of discovering no more than those mentioned affected. These
six children all slept in the same dormitory, a large oblong ward, in which
there were nineteen single beds, all occupied. Close questioning elicited
the information that during the night the girls would creep occasionally
into bed with each other, and one of the children confessed that some of
the larger girls were in the habit of titillating the genitals of the smaller
ones with their fingers, buttons, sticks, etc. Now, the mere fact of the
titillation would not suffice to account for the sudden outbreak of vulvitis
446 Atkinson, Contagious Vulvitis in Children. [April
in these girls ; it would, however, be sufficient to prove a ready manner of
conveying a contagious principle from one child to the other, could such a
principle be supplied.
For a year or eighteen months past the institution has been, from time
to time, pervaded by a contagious ophthalmia, which has almost baffled the
careful efforts of the officers. During its prevalence nearly all the in-
mates, including some of the attendants, have been affected, and the most
careful isolation has served to do hardly more than check the malady
temporarily. At the time of the appearance of the vulvitis, two or three
cases of conjunctivitis were in the infirmary. Coexisting with the oph-
thalmia there have been an unusual number of cases of catarrhal and
ulcerative stomatitis, and upon two or three occasions so many children
were affected that Dr. Tiffany, who at the time was in charge, was con-
vinced of the contagious nature of the disorder, and attributed its origin
to the ophthalmia. In a like manner I am persuaded the discharges
from either the ocular or buccal mucous membranes were conveyed to the
vulval mucous membranes of my patients, in some manner, most probably
upon the fingers of some of the girls, and was the active cause in the pro-
duction of the vulvitis.
The potentiality of the products of inflammation of the genital mucous
membranes to induce by contact severe ophthalmias is well known and
universally admitted ; the contagiousness of catarrhal and ulcerative stom-
atitis has been claimed in accounting for certain epidemics of buccal in-
flammation ; although, indeed, many writers are unwilling to accept the
latter claim as valid. Analogy would seem to justify the view that in a
like manner contagium from other mucous membranes may light up in-
flammations in that of the vulva, a conclusion to which the cases above
mentioned would likewise direct us. It is not necessary, in the present
instance to search for such epidemic influences as are usually claimed to
originate vulvitis in children when widely distributed ; for we have a more
tangible agent of contagion in the pus that has so successfully carried dis-
ease to many persons in the institution during many months ; in fact, the
origin of the cases is as readily accounted for as if we knew that gonor-
rheal pus had been brought into contact with the vulval mucous mem-
branes of these children, and their interest rests in the circumstance that
there was here a vulvitis due to a specific contagion other than venereal.
In view of the popular disposition to attribute such maladies in young
children to criminal causes, the bearing of these cases is obvious.
1878.]
Hartshorn e, Ophthalmic Physiology.
447
Article XVIII.
A Commonly Accepted Theory in Ophthalmic Physiology Disproved
by a Crucial Experiment. By Hexry Hartshorne, M.D., of Union
Springs, N. Y.
Haying become satisfied by various evidence that the theory usually
given in the text-books, on the authority of Helmholtz, to account for
what are called ocular spectra, negative and complementary, is erroneous,
I wish to call the attention of physiologists to a very simple but decisive
experiment, whereby it may. in my judgment, be disproved.
The class of tacts to be explained may be recalled by a single example.
Let any one look for a few moments steadily, under a good light, at a red
surface of any kind, an inch or two square. Then let the eyes be turned
upon a larger white surface; there will be seen a patch of green, of the
form of the red surface first looked at. What is the cause of this ?
The ordinary explanation given is, that, by looking at a red object, the
retinal nerve-elements by which red light is perceived become for the
time fatigued, and so less sensitive than the other portions of the retina;
and hence, of the light reflected from a white surface, only the comple-
mentary colour to red, viz.. green, is seen. In a paper published in the
Proceedings of the American Philosophical Society for 1876, I stated at
length the experimental evidence which I believe to render it impossible
for this explanation to be correct. I propose now to mention an addi-
tional experiment, by which any one may readily put it to the test of
observation.
An hour (or less, with sensitive eyes) before sunset, let any one, having
normal sight, look for from five to ten seconds at the sun through a pair of
blue or green glasses, such as are worn at the sea-shore or elsewhere to
protect the eyes from glare. Then, on closing the eyes, there will be
visible a spectrum of the sun, of the same colour as that of the
glasses through which it was looked at. Then let the eyes be opened
upon a white surface (snow is the best possible), the glasses being removed.
At once, or very soon, will be seen a spectrum of the colour complementary
to that of the glasses. Again let the eyes be closed ; the positive spec-
trum will return; i. *>., of the same colour as that of the glasses through
which the sun had been seen. Several times this may be repeated before
the spectra fade away and disappear.
Now it appears to me to be self-evident that, if looking at the sun
through glasses of a certain colour produced fatigue in those elements of
the retina by which that colour is perceived, we should not see a spectrum
of the same colour, when the eyes are closed. That this is not explained by
the resting of the fatigued nerve-elements by closing the eyes, is obvious ;
because, when they are opened, a negative or complementary spectrum is
448 Glisan, Strychnia Poisoning treated by Apomorphia. [April
at once seen ; and this again and again. It is impossible for fatigue to
account for both positive and negative spectra at the same time; i. e., at
successive and alternating moments. Indeed, I consider it impossible
that fatigue should explain positive spectra at all.
How, then, do we interpret the phenomena referred to? The positive
spectrum I account for by the reverse of fatigue ; namely, strong excitement,
and (physically expressed) continued vibration of those retinal elements
which respond to the colour interposed between the eyes and the sun.1
The negative or complementary spectrum is to be explained, in my judg-
ment, by the interference of the above-named continued retinal vibrations,
with those rays of the same colour in the light reflected by the white sur-
face looked upon; so that only the complementary rays are seen.
This is, it may be said, a physical instead of a physiological explanation
of the facts observed. It exemplifies the large place necessarily awarded,
in modern physiology, to physical phenomena and causation. A general
statement may be formulated, as follows : those ethereal vibrations which
we know as light, impinging upon the retina, produce in its receptive
structure corresponding vibrations, which are a constant and necessary
part of the mechanism of vision.
This last expression may seem, perhaps, especially unacceptable just
now; when, after the thermo-dynamic theory of Draper, and the electri-
cal hypothesis of others, the observations of Boll and Kiihne have re-
cently made popular & photographic theory of the function of the retina.
But it remains to be proven how far the phenomena which have suggested
these different hypotheses may be concomitant with, rather than essential
to, vision. At all events, any theory of vision which excludes the idea of
retinal vibration in response to the wave-movements which are known to
constitute light, if accepted at all, must be supported by overwhelming
evidence; such as has not yet been anywhere adduced.
Article XIX.
Successful Treatment of Strychnia Poisoxixg by the Hypodfrmic
Injection of Apomorphia. By R. Glisan, M.D., Professor of Obstetrics,
etc., in the Oregon Medical College, Portland, Oregon.
In the course of twenty-nine years' practice of my profession I have
never met with an instance of poisoning by strychnia that has given me
in its treatment, considering the quantity of the poison taken, the satis-
faction derived from the following case : —
1 This may be called a kind of retinal phosphorescence.
1878.] G lis an, Strychnia Poisoning treated by Apomorphia. 449
At 3^- P. M. of December 3d, 1877, I received a hasty summons to see
Mr. R. C. W., aged 25 years, who was supposed to be dying. On arriv-
ing I found him in terrible tetanic convulsions from a dose of the sulphate
of strychnia, which he had taken witji suicidal intent a short time before
my arrival. His legs and arms were extended, hands clenched, feet and
toes incurvated, and his body was rigidly arched backward and resting
on his heels and the back of his head. In short, all of his muscles seemed
to be in a state of rigidity. There were also the risus sardonicus, and a
general cyanosed appearance of the skin.
During the paroxysm the pulse was too frequent to be counted, and his
pupils were slightly dilated. Finding it impossible, on account of trismus,
and the violence of the general spasms, to administer an emetic by the
mouth, or to use the stomach-pump, and having a grain of E. Merck's
muriate of apomorphia in my pocket, I injected one-third of it, dissolved
in a little water, beneath the skin of the anterior part of his right forearm.
In half a minute the paroxysm subsided, and was followed in about five
minutes by another of shorter duration and of less violence ; during the
height of which vomiting commenced and actively continued until his
stomach was emptied of its contents.
After the vomiting there was no recurrence of the general tetanic
spasms, but an occasional slight contraction of a few muscles, when the
patient was touched, moved, or in any way disturbed. He said that lie
had had several convulsions before I saw him, and that they had increased
in frequency and force up to the time of his receiving the hypodermic
injection.
After vomiting freely from the action of the muriate of apomorphia, he
took in divided doses the following emetic, in order to insure a thorough
evacuation of the stomach. Although this additional emetic was undoubt-
edly superfluous, I gave it because it could do no harm, and might do
good. R. Pulv. ipecac. 5u> zinci sulph. gr. x, pulv. sinapis albse gr. x,
mixed with a little warm, sweetened water. I also gave him freely a tepid
mixture of equal parts of olive oil, milk, and water ; thus keeping up the
vomiting for about fifteen minutes. The occasional, very slight, and par-
tial spasms that occurred at long intervals only once required any special
attention, when I permitted him to inhale a small quantity of ether.
After the entire subsidence of the spasms, or about an hour from the
time of my first seeing him, I ordered that half a drachm of bromide of
potassium should be given him at 9 P. M., and then took my departure.
On calling the next morning, I found him well, but still feeling some
muscular soreness and fatigue, and fully resolved to let strychnia alone
in the future. He said that no one could imagine the fearful agony it had
caused him, and that he would rather be burnt to death than again suffer
the pangs that he had endured from this horrible poison. He told me
also that after taking the strychnia he locked the door of his room, and
lay down on his bed to die, as he supposed, in a rapid and easy manner.
When the spasms commenced they soon put him in such fearful agony that
he screamed for help. His cries attracted the attention of a man in a
room below him, who ran up and broke open the door, and sent for me.
I do not believe that the one-sixteenth of a grain of apomorphia, the
dose usually recommended, and especially by Professor Bartholow, for
hypodermic injections generally, would have been of much service in the
case of my patient ; yet this quantity is undoubtedly sufficient in ordinary
450 Conner, Subacromial Dislocation of the Humerus. [April
cases of disease, and has even proved fatal in a man affected with "chronic
bronchial catarrh and moderate emphysema."1
About two years ago I was strongly tempted to use apomorphia in an
instance of poisoning by laudanum, but the rapidly supervening narcosis
deterred me from so doing ; and I frankly admit a prejudice against its
employment in narcotic poisoning generally and in ordinary forms of dis-
ease requiring emetics, because of the occasionally dangerous results
where vomiting is not produced. But I believe that it is pre-eminentlv
adapted to poisoning by strychnia on account of the twofold action of
antagonizing the rigidity of the muscular system, and of promptly reliev-
ing the stomach of the unabsorbed portion of the poison.
Whilst admitting the possibility of the rapid abatement and final cessa-
tion of the spasms being simply coincident with, and not the result of, the
action of the apomorphia in Mr. W.'s case, yet I have seen a sufficient
number of examples of the toxicological effects of strychnia upon the
human subject to form a reasonable prognosis in a given instance, and I
must declare my firm conviction that death was chiefly prevented by the
prompt action of the muriate of apomorphia.
The precise quantity of strychnia taken by Mr. W. could not be ascer-
tained, but was probably about six grains. My estimate is based upon
his statement after recovery. A paper, from which he said he took it. was
found in his room during the paroxysms, containing a little of the poison.
He supposed that there was an interval of about half an hour between the
time of taking the strychnia and my arrival.
So far as I know, this is the first case of strychnia poisoning in which
the muriate of apomorphia has been used, and I feel confident that this
salt will be found, on further trial, the remedy, par excellence, in those
cases of poisoning by the active principles of mix vomica, where & prompt
emetic is indispensable, and cannot be given by the mouth, and where a
moderate degree of antagonism is sufficient to counteract the effects of the
poisonalready absorbed into the system.
Article XX.
Backward (Subacromial) Dislocation of the Head of the Humerus ;
Reduction on the Twenty-ninth Day. By P. S. Conner. M.D..
Professor of Anatomy and Clinical Surgery in the Medical College of Ohio, etc.
On the 8th of February, G., set. 39, a powerful, muscular man of me-
dium height, consulted me on account of some trouble about the right
shoulder, which had existed for four weeks, and been treated as a sprain
and rheumatism. He stated that on the 11th of January he was sobering-
1 Medical Record, Oct, 20, 1877, p. 661.
1878.] C oknee, Subacromial Dislocation of the Humerus
451
up after a heavy spree, and late in the day fell asleep, but wakened after
an hour or two, crying out " Oh ! my arm ;" and as soon as he was fully
conscious, he felt great pain about the right shoulder. A " blue spot" was
noticed at the region of the deltoid insertion. The physician who was
called in regarded the case as one of sprain, and treated it accordingly.
The pain gradually diminished, but never entirely ceased ; and the whole
extremity continued to be quite powerless ; as the patient expressed it, "it
was numb, as if it was asleep all the time." Nine years previously this
same right shoulder had been luxated ; and again three years ago there
had been some injury of it, the exact nature of which was not known.
Upon examination, at the date above mentioned, I found the arm hanging
by the side and rotated inwards, the external condyle of the humerus look-
ing forwards and inwards. There was almost entire inability to lift the
arm away from the body, and it could not be rotated outwards. The
antero-internal surface of the shoulder was flattened, the corresponding-
margin of the acromion sharply defined, with a depression below it, and an
evident fulness underneath and posterior to its outer border. The dis-
tance from the acromion process to the outer condyle of the humerus was
in. less, and the circumference around the axilla over the acromion and
the prominence postero-externally was over an inch greater than on the
sound side.
On the following morning (the twenty -ninth day after the receipt of the
injury) the man was etherized, and after very considerable effort the head
of the humerus was replaced in the glenoid cavity, the reduction being
accompanied by a distinct snap, notwithstanding the completely anaesthe-
tized state of the patient. At the time of the reduction the extending
force was being exerted from above and within, and aided by the direct
pressure I was making upon the head of the bone. The after-history of
the case presented nothing of special interest, and all bandages were re-
moved at the end of two weeks — the patient keeping the arm quiet for
some days longer.
How the accident was produced cannot of course be told, the man being
asleep and alone at the time. It is possible, not to say probable, that, re-
covering as he was from a protracted debauch, the patient had an epilep-
tiform attack, in which the dislocation was produced, either by muscular
action or by striking the arm against some part of the bedstead. Muscu-
lar action is certainly a frequent cause of the backward dislocation, more
than one-fourth (^g-ths) of the cases, according to Malgaigne, having been
thus produced, the humerus having been violently twisted inwards.
It will be noticed that I have reported the arm as somewhat shortened.
Respecting the change in length very contradictory opinions have been
expressed. Sedillot, in the report of his case in which he effected reduc-
tion a year and fifteen days after the luxation occurred, says that "the
arm, measured from the summit of the olecranon to the outer border of the
acromion, was an inch longer than that of the opposite side." Gross de-
clares that the arm is considerably shorter than natural." Xelaton
finds that " the member is longer than that of the sound side," and Follin
that there is " ordinarily lengthening ;" while Flowers maintains that " the
length of the arm is unaltered or but slightly increased," and Panas that
452 Packard, Primary Anaesthesia from Sulphuric Ether. [April
there is ''little or no lengthening, sometimes even there has been reported
a certain degree of shortening." Many of the standard authorities (among
them Cooper, Hamilton, Bryant, Erichsen, Holmes, Ashhurst, Gant)
say nothing about the length of the limb.
The rarity of backward dislocation (less than fifty cases being on re-
cord) makes it advisable, I think, that every accident of the kind should
be reported, especially as it is not infrequently, as in the case I have nar-
rated, mistaken for an unimportant injury or disease of the shoulder. For-
tunately, even when such mistake has been made, and considerable time
has elapsed since the dislocation, the probability of reduction is greater,
and the period of time within which efforts at restoration may properly be
made is decidedly longer, than when the luxation is of one of the more
common varieties.
Cincinnati, 122 Seventh St.
Article XXI.
On the Primary Anaesthesia from Sulphuric Ether.
By John H. Packard, M.D., of Philadelphia.
Since the publication of my article on the above subject in the number
of this Journal for July, 1877, various inquiries have been made of me, by
.letter and otherwise, in regard to it ; and I feel called upon to be more
explicit upon one or two points.
As before stated, the time occupied in inducing the first insensibility
varies in different persons. In some it comes on almost immediately ; in
others it is delayed for several minutes. When it is thus delayed, the
operator or the assistant may either despair of its coming at all, or assume
that it has passed unnoticed.
It must be remembered that this is a distinct stage. Every one knows
that patients will often lie so still that they are thought to be insensible ;
but at the touch of the knife there is instant shrinking and perhaps outcry.
The only reliable test of this stage of primary anaesthesia is the failure of
muscular power, as shown by inability to maintain the hand outstretched.
Hence the necessity of watching for this sign ; urging the patient to hold
up his hand, especially if he tends to lie quietly.
I feel warranted in asserting that this " first insensibility" invariably
occurs ; that it is absolute and profound, though brief ; and that it may
always be detected and taken advantage of by careful observation and
prompt action.
1878. |
453
REVIEWS.
Art. XXII Spinal Disease and Spinal Curvature. Their Treatment
by Suspension and the use of the Plaster of Paris Bandage. By
Lewis A. Sayre, M.D., of New York, Professor of Orthopaedic Sur-
gery in Bellevue Hospital Medical College, New York, etc. Duode-
cimo, pp. ix., 121. London: Smith, Elder & Co. Philadelphia: J.
B. Lippincott & Co., 1878.
Owing to the conspicuously pitiable deformity resulting from the de-
struction oF the vertebral bodies, the subject of spinal curvature always
received the attention of surgeons, but it remained for that acute and in-
dependently thinking man, Percival Pott, to give to the profession the
first rational and systematic account of the etiology and progress of a dis-
ease which claimed its victims from every rank of society, and asserted
its importance by the terrible distortions familiar to every observer. The
works of Pott are but little read now, although written in a style which
many modern authors might well copy, yet while they are hardly known
among the surgeons of to-day, their author was prominent among those
men of the last century who did for surgery what Petrarch and Bocaccio
did for general literature at its renaissance. But the surgeons among
whom Pott occupied so conspicuous a place did not merely renew an ex-
tinct or slumbering art, they were creators, so far as the term can be pro-
perly applied to the disciples of an inductive science, and from carefully
made observations deduced the general laws which governed the produc-
tion of the diseases of which they treated. Every one who would famil-
iarize himself with the pathological facts concerned in antero-posterior
curvature of the spine must go back to the writings of Pott, but he need
go no further, and it is upon the facts he first demonstrated, and the theo-
ries and treatment he proposed, that accretions have gone on accumulating,
until we have the advanced science of to-day, the last development of
Avhich, in this particular direction, is to be found in the little book whose
title prefaces this review.
A little more than a year ago it was the pleasing duty of the writer to
present to the readers of this Journal a review of Dr. Sayre's book upon
Orthopedic Surgery. In that volume there was a short account of the
new plan of treating antero-posterior curvature of the spine by means of a
plaster of Paris jacket, and we then thought that we were justified in an-
ticipating great results from that incipient method. While the review of
which we speak was in the hands of the printer, Ave witnessed the ap-
plication of the plaster jacket upon the person of two patients, by Dr.
Sayre, at the meeting of the American Medical Association held at
Philadelphia in 1876. At that time it was a matter of regret that the
writing of the article referred to had not been postponed until the demon-
stration given by Dr. Sayre would have enabled us to speak more con-
fidently of the great discovery, for such it truly is, of this most happy
application of plaster of Paris. Since June, 1876, the plan of treatment,
454
Reviews.
[April
then so ably enforced by the distinguished professor of Bellevue, has had
wide-spread attention directed to it, and, so far as we are informed,
without unfavourable comment.
That counter claims for the merit of the invention should have sprung
up has been a matter of course, and we are constantly reminded that it
does not belong to Dr. Sayre, that the idea occurred previously to some
one else. To discuss the question of such claims for priority is at best a
very profitless occupation, and it is not proposed to enter into it in this
review. All great discoveries, without exception, have been the result of
progressive observations, and since the first introduction of plaster of
Paris for the construction of immovable dressings the range of this appli-
cation has become more and more extended, so that it cannot be a matter
of surprise that it should have occurred to .several besides Dr. Sayre, that
in it would be found a valuable means of maintaining extension in cases
of Pott's disease. But it is one tiling to have a vague and shadowy idea
floating through the mind, or even to make one or two hesitating trials of
its efficiency in practice, and quite another to put it fearlessly and confi-
dently in practice, in a series of cases, modifying without deserting the
principle, and then with equal perseverence and energy to publish the re-
sults thus obtained. With characteristic impetuosity, undisturbed by the
criticisms and sneers of many among his professional brethren, with a
most fortunate and wonderful indifference to the opinions entertained by
others of either him or his methods, Dr. Sayre has held on his way, lec-
turing, demonstrating, writing, and publishing, until, as his crowning con-
tribution thus far to surgical literature, we have this brochure on the
treatment of spinal curvature by means of the plaster jacket, an apparatus
whose unyielding embraces have already brought comfort and happiness
to many unfortunates.
While Mr. Pott was the first to point out that the deformity and pa-
ralysis in these cases depended upon destruction of the vertebral bodies,
caused by tuberculous degeneration, he shared the antiphlogistic opinions
of his time, and confined his treatment to the use of derivatives in the
shape of setons and issues, applied on either side of the spinous processes,
and kept open for long periods. A later pathology has taught us that
where tubercles do exist, the most hopeful treatment is that which consists
largely of tonics, fresh air, and nourishment. Of late years the wonderful
progress of the mechanical arts has exerted an important and beneficent
influence within the domain of surgery, and, as the opinions of our prede-
cessors have been proved erroneous in many particulars, there has been
more and more attention directed to the proper mechanical treatment of
spinal curvatures, while the existence of constitutional depravity has re-
ceived its proper share of attention. But Dr. Sayre has taken a new de-
parture, and his views of the pathology of spinal curvature are in direct
opposition to the opinions once held by all, and yet stoutly maintained by
many. While he does not altogether deny the existence of scrofula, he
entirely excludes it as a factor concerned in the production of spinal cur-
vature, and, provided the proper mechanical treatment is adopted, seems
to regard with indifference the question of systemic taint. Even when he
prescribes cod-liver oil and other nourishment, he is very particular to
inform us that it is with no idea of combating a scrofulous diathesis. In
this extremity of view he is opposed by many high in authority, and has
arrayed against him the weight of surgical experience. When reviewing
Dr. Sayre's work on orthopaedic surgery, the writer expressed his dissent
1878.] Satre, Spinal Disease and Spinal Curvature.
455
from the theories of its author on this point; so that it is not worth
while to again discuss the question. Especially is this the case, as the
difference is more theoretical than practical ; for so long as Dr. Sayre's
patients receive the treatment which his opponents unite in regarding as
most advantageous for those afflicted by scrofula, it will make little differ-
ence to them that their surgeon denies that they are under the influence
of anything bearing that name. Indeed, the mechanical devices brought
to such perfection by Dr. Sayre all aim at getting the patient into the
fresh air, that best of all tonics, and, in accomplishing that end, they are
the most efficient antagonists of scrofula which we possess.
We come now to the central idea of this little volume, the method
introduced to the profession by its author. This method, for we do not
like to call it an invention, has that essential element of simplicity, with-
out which the most ingeniously devised mechanical appliances rarely be-
come available in practice. With reasonable care and that attention to
details which every competent practitioner of medicine soon learns to be-
stow upon any plan of treatment he adopts, there is no room for failure ;
and if evidence of the unselfishness of Dr. Sayre were wanting, it would
be furnished by his true statement that this method does away with the
necessity of sending patients long distances to obtain skilled treatment at
the hands of a specialist ; for any properly, that is, regularly, educated
physician should be able to make the application at home, and obtain per-
fectly satisfactory results there, quite as good as if the patient were under
the hands of Dr. Sayre himself.
In furtherance of this end, and with the hope of making this method
plain to those who may not meet with the volume under review, we shall
now attempt to describe the steps by which Dr. Sayre and others have
been enabled to achieve such decided and satisfactory results.
The patient is first provided with a closely-fitting undershirt, which is
prevented from riding up by straps extending from the front and back of
the garment, which are securely tied over a pad placed upon the perineum.
Due precaution having thus been taken to prevent folds, which might
cause excoriations, the patient must be properly suspended. To accom-
plish this part of the proceeding, Dr. Sayre makes use of a collar, upon
which rest the chin and occiput of the patient. This collar is then at-
tached by straps to an iron cross-piece, which, in turn, is suspended, by a
ring in its centre, to a block and pulley attached to a hook in the ceiling
or a tripod especially constructed for the purpose. Just enough extension
is then applied to take the weight of the body off the spinal column, which
limit is known to be reached by the relief expressed by the patient, and is
evidenced in children by their becoming quiet, and ceasing to struggle.
It is generally sufficient to raise the patient just so that his toes touch the
ground, but he must not rest upon them, so as to give any twist to the
body. While the suspension is thus kept up, plaster of Paris bandages
are applied. These rollers are prepared in the usual way, by being drawn
through freshly ground plaster, which is also rubbed into their interstices,
and they are kept in a carefully closed tin box until required for use.
Dr. Sayre recommends that the thin and flimsy stuff known as crinoline
should be used for making these bandages, on account of the amount of
plaster that can be rubbed into its meshes. Before applying the bandages,
it is necessary to place over the epigastrium a long, narrow compress.
This compress Dr. Sayre, with his usual unhappy system of nomenclature,
calls the " dinner pad." Of the importance of this pad in affording, after
456
Reviews.
[April
its removal, room for abdominal distension, there can be no doubt ; and
while we look askance at our author's choice of a name, we are quite
ready to indorse the prominent attention he bestows upon the thing itself.
It consists of a wedge-shaped compress, with its thin edge directed down-
wards, and should be extracted just before the plaster becomes firmly set.
By means of this device there is a vacant space left underneath the jacket,
which permits of some expansion of the abdomen after a full meal. The
omission of this compress may entail much unnecessary discomfort upon
the patient. The same principle or manoeuvre is taken advantage of to
protect any prominent spinous processes, the crista ilii, and, in the case of
developing females, the breasts.
The bandages are placed in warm water and kept there until bubbles
are no longer given off, and then applied, beginning at the smallest part of
the trunk, going down below the crests of the ilii, then returning upwards
to the upper part of the axilla. After applying one or two layers of band-
age Dr. Sayre makes use of several narrow strips of sheet-tin, roughened
on both sides by holes punched after the manner of a nutmeg grater.
These are applied to the sides longitudinally, their object being to supply
the requisite strength to the jacket without adding too much to its weight
and bulk. Another bandage is then applied, and the process is repeated
until sufficient firmness and strength of jacket is obtained.
After the plaster of Paris has partially set the patient is removed from
the suspensory apparatus and laid upon a hair mattrass, or air bed, to dry.
The famous " dinner pad," and any other compresses which have been
made necessary by the peculiarities of the case, are then removed, and
weak spots in the jacket, which will commonly be found in spite of every
care in its application, are strengthened by dusting in more plaster. Dr.
Sayre also advises that indentations should be made in the jacket imme-
diately above the crista ilii to give it greater breadth at that part.
When abscesses exist they should be freely opened, Dr. Savre's practice
being to do it antiseptically, and after the application of the proper dress-
ing they should be covered with oiled silk, or, as we should prefer, with gum
tissue. Over the oiled silk Dr. Sayre places a piece of pasteboard, with a
pin thrust through it from within outwards. By this means the projec-
tion of the pin through the successive layers of the jacket will afford a sure
guide to cut down upon and remove the piece of pasteboard when the
plaster is nearly set. After removing the pasteboard the oiled silk or gum
tissue can be cut in lines radiating from the centre of the abscess, and the
ends fastened down to the jacket by means of shellac. By this contrivance
direct communication is afforded to the abscess, and the proper treatment
of it can be carried on without removing or disturbing the jacket.
We come next to what Dr. Sayre, with apparent pride, calls his "jury-
mast apparatus," wdiich he uses in cases where the cervical vertebras are
involved, and where, of course, mere extension of the dorsal and lumbar
vertebras do no good. We presume this title was supposed to be particu-
larly intelligible and attractive in Great Britain, where the book was pub-
lished, and whose people, as rulers of the sea, may be supposed to be spe-
cially conversant with marine terms. To many of Dr. Savre's American
readers, however, as inhabitants of inland regions, it will not appear to
have any peculiar fitness. Apart from its very peculiar name, we do not
see that Dr. Sayre has any reason to claim this as his apparatus, for the
plan of its construction does not differ from similar machines devised by
others, excepting in so far that its lower end is secured to a plaster jacket.
1878.]
Sayre, Spinal Disease and Spinal Curvature.
457
The lower part of the implement has attached to it strips of roughened tin,
which partially encircle the chest walls. These strips are placed in position
when one or two thicknesses of the plaster roller have been applied, and
the jacket is then completed over them. To the projecting and stationary
part of the apparatus, thus having its extending points on the surface of the
trunk, is then added a properly curved rod of steel, which, reaching above
the head, has secured to it by straps in the usual manner a collar, by which
the head can be suspended and extension of the cervical vertebrae kept up.
The effects of applying the plaster jacket are immediate, and are painted
in glowing colours both by Dr. Sayre and many others who have used it at
his suggestion during the past two years. When the pathology of the
disorder is considered in connection with the indications so well fulfilled
by the plaster jackets, it can surprise no one that the lame should walk
and leap after its application, or that both the patients and their friends
should justly look with gratitude to the introducer of this remedial measure.
Passing over the laudatory letters and the numerous cases related at
length in which Dr. Sayre and others at his instance have used plaster of
Paris in the treatment of Pott's disease, we proceed to notice the remarks
made upon the subject of lateral curvature of the spine. Dr. Sayre pro-
poses to call this form of curvature, rotary-lateral curvature, on account of
the rotation of the vertebral bodies known to exist in these cases. In dis-
cussing the cause of this rotation, which has always proved a troublesome
feature in the treatment of this affection, Dr. Sayre quotes freely from a
paper read by Dr. A. B. Judson before the New York Academy of Medi-
cine. In this paper it is shown that as the muscular attachments of the
vertebrae are all connected with the processes, which are also confined by
their articulations and their position in the chest walls, any disturbance
of equilibrium between the forces of the two sets of muscles which results
in a yielding of the bone to the stronger side must compel a rotation of
its body as a consequence. By an ingeniously' contrived mechanism Dr.
Judson demonstrated that compression of the spinal column, when one of
the vertebrae is more firmly held by the attachments of one side than by
those of the other, produces a curve at that point. In the same paper Dr.
Judson suggested the application of sustained extension in these cases.
Some years ago the late Professor Mitchell, of Philadelphia, used to
treat cases of lateral curvature by suspending them by the arms, and he
encouraged them to make the attempt themselves ; but to Dr. Benjamin
Lee, of the same city, is justly due the credit of having first systematically
taught his patients to practice self-suspension, by climbing up a rope which
passed over a pulley and was attached to the patient's head by straps,
passing under the chin and occiput. This is the plan of treatment upon
which, with the addition of the plaster jacket, Dr. Sayre now depends.
Our author is very emphatic in denouncing the contrivances so often
resorted to in this kind of deformity, in which, while various levers and
screws are resorted to to correct the trunkal twist, some of the bands of
the appliance pass over the shoulder, and thus entirely prevent a proper
extension of the spinal column. This plan he likens to a man who should
make the two ends of an S-shaped piece of wire fast to a board and then
try to straighten the curves by pressure.
To remedy the condition of things existing in this class of cases, Dr.
Sayre finds the application of the plaster jacket a very valuable addition to
Dr. Lee's plan of self-suspension, making the application in the same manner
as he directs in cases of Pott's disease. By this combined treatment,
No. CL — April 1878. 30
458
Reviews.
[April
while moderate extension is kept up, and the tendency to rotation is over-
come by the removal of compression from the vertebral column, the mus-
cles at fault are at the same time stimulated by exercise to contract in a
healthy manner, and are helped to regain their normal power. Dr. Sayre
directs that in the act of self-suspension there should be no axillary bands,
but that the collar only should be used, and that in making traction upon
the fall the hands should be kept above the head. While the self-suspen-
sion is maintained it is important to see that the upper hand should always
be the one corresponding to the side on which the concavity in the dorsal
region exists.
Having now followed Dr. Sayre through the substance of this volume,
it but remains for us to express our sense of the great service he has ren-
dered the profession by its publication. We have been compelled to smile
at some of the author's peculiarities of style, and have had to dissent from
him in some matters of taste ; but such trivialities, while they may mar the
book, do not effect the value of its substance and conclusions. The
method introduced by Dr. Sayre is one which cannot be too highly com-
mended, as we cannot conceive of a case, suited for treatment at all, in
which it is not likely to prove advantageous. The fruits of this method
will not be confined to the rich alone, but it will prove a boon to the
poorer classes of patients, and those who are obliged to depend for their
surgical treatment upon public charity. In dispensaries the treatment so
clearly laid down by Dr. Sayre should become the established one. With-
out being over sanguine, we may reasonably indulge the hope that the day
is not far distant when our eyes, or those of our successors, will not so
frequently be pained at the sight of deformity produced by the ravages of
antero-posterior curvature of the spine ; when the wan face and unhappy
expression of its victims shall not so often testify to lives embittered and
tempers soured by the suffering of body and anguish of mind consequent
upon the unchecked progress of Pott's disease. Although we do not look
upon the process of Dr. Sayre as presaging the advent of millennial happi-
ness, for we know that many cases will persist to an untoward result de-
spite the best treatment, yet there is no pleasanter occupation for a lover
of our race than that of contemplating every fresh evidence of the pro-
gress our science is making in the alleviation of human misery.
While day-dreaming may be somewhat out of place in the sober pages
of a medical review, yet, in the face of decided advances in treatment, we
can well understand some one speculating upon the effect that this or that
discovery, if made earlier, might have had on the events of history. It
has been said that dyspepsia has decided the fate of nations, and in view
of Dr. Sayre's method of treating spinal curvatures, Ave can fancy the same
person suggesting that, had the third Richard been treated with a plaster
jacket in his youth, the fate of England might have been different, and the
world have lost a character which under the magic touch of genius has
given delight to every reader of Shakespeare.
While the photographs in this book make the process of applying Dr.
Sayre's dressing very plain, they have the awkwardness of all folded plates,
and make the price of the volume very high ; but had they been omitted,
the bluff features of Dr. Sayre, looking his best, would not have been so
familiar to his readers. To many it would have seemed in better taste,
and more satisfactory in cost, to have had one or two good wood-cuts,
even had they shown nothing but the process the book was written to
enforce. S. A.
1878.]
Althaus, Diseases of the Nervous System.
459
Art. XXIII Diseases of the Nervous System : Their Prevalence and
Pathology. By Julius Althaus, M.D., M.R.C.P. Lond., Senior
Physician to the Hospital for Epilepsy and Paralysis, Regent's Park,
etc. etc. 8vo. pp. xvi., 366. New York : G. P. Putnam's Sons, 1878.
Among the unsettled questions in medicine, few have recently been the
subject of so much discussion as that in regard to the comparative preva-
lence and mortality from diseases of the nervous system in this and former
times. By many, both in and out of the profession, the assertion is con-
fidently made that there has been of late years a progressive increase of
deaths from these diseases, and inasmuch as there has probably never been
in the history of man a time in which the struggle for existence has been
keener, or the mental development and strain greater, than in the present,
it would seem not unlikely that this opinion was susceptible of easy proof.
And yet, when the facts upon which it rests are subjected to a rigid ana-
lysis, it is found that they do not positively sustain it. Indeed, so far is
this from being the case, that Dr. Roberts Bartholow found himself com-
pelled to reply in the negative to the question, " Do the conditions of
modern life favour specially the development of nervous disease ?" in the
able and instructive paper with which he opened the discussion on this
subject at the late International Medical Congress at Philadelphia.
In the volume which forms the subject of this review, Dr. Althaus en-
deavours to elucidate the part played by diseases of the nervous system in
the pathology of Great Britain, and to show the laws to which their occur-
rence and fatality are subject. In order to arrive at truly reliable and
definite results he has had recourse to the Annual Reports of the Regis-
trar-General on disease and death. These, as he says, have enabled him
to deal not with hundreds or thousands, but with hundreds of thousands of
cases, extending not only over a few years, but over a considerable period
in the life of the nation, or, from 1838 to 1871 inclusive. There is, of
course, in these reports, the source of error that, as they are made up from
the certificates of death filled up by the entire body of medical practitioners
in the kingdom, there may have been in some cases errors of diagnosis;
but the author is convinced that, with the exception of the first few years,
the errors under this head cannot amount to anything very considerable.
As the general result of his researches on the entire class of nervous
diseases, Dr. Althaus announces the following proposition : " The rate at
which diseases of the nervous system prove fatal to the population of this
country [England and Wales] is a steady one, subject to a definite law,
to which there are not any apparent exceptions. This rate does not ap-
pear to vary perceptibly from time to time, and amounts to about twelve
per cent, of the entire mortality from all. causes." As this proposition ap-
pears to be fully sustained by the figures he adduces, it seems to us that
the common opinion that nervous diseases have considerably increased
during the last decennial must be admitted to be unfounded. The author's
investigations have also led him to the conclusion that diseases of the ner-
vous system occupy the fourth rank amongst the maladies destructive of
human life, being only surpassed in fatality by zymotic, tubercular, and
respiratory diseases.
The two preceding propositions, opposed as they are to the preconceived
notions of many, will probably nevertheless excite less surprise and oppo-
sition than the third, which is as follows : " Nervous diseases are not, as
460
Reviews.
[April
is commonly asserted, more frequent, but, on the contrary, less numerous,
in large towns than in the country, and it is probable that their occurrence
is powerfully influenced by^race." In support of this proposition, he shows
that the death-rate in London from these diseases was 10. GO per cent, of
the mortality from all causes ; while it was 11.20 in the southwestern
counties of England, and 15.38 in Wales — that is, nearly 5 per cent, more
than in London. " That the nervous system should be more liable to
break down in the fine and wholesome atmosphere of agricultural districts
than in the close and foul air of the courts and alleys which abound in
great cities, seems," the author says, " to show that excess of manual
labour is more exhaustive to the nervous system than excess of mental
labour, and that the more nourishing and substantial food which is enjoyed
by even the poorest classes in London, as compared with their brethren in
the country, more than compensates them in this respect for the advan-
tages the country affords as far as air and climate and the supposed whole-
someness of rural pursuits are concerned." It would be interesting to
know whether or not the same rule obtains in regard to the mortality from
these diseases in the United States, where destitution is comparatively
infrequent, and where the population is, as a rule, so much better housed
and fed in the country than in the cities ; but, unfortunately, there are
no statistics available for the solution of this question.
The remaining propositions are much more in accordance with the
views generally held on the subject of nervous disease, and we shall there-
fore simply state them. They are as follows : —
1. " Sex has a powerful influence on the production of nervous diseases; for,
although in this country the population of females exceeds that of males, the
deaths of males from nervous affections preponderate constantly over those of
females ; the male death-rate being 12.94, and the female 11.62 per cent."
2. " Age has even a more powerful influence on the production of nervous dis-
eases than sex ; for these maladies attain an immense maximum in the first year,
owing to the great prevalence of infantile convulsions. They are much less fre-
quent in youth and middle age, and attain a second maximum in old age — that is,
after seventy — owing to the prevalence of apoplexy and paralysis ; but the second
maximum amounts to only about the tenth part of the first maximum attained
during infant life."
In regard to the classification of nervous diseases, the author says, the
most simple and, in a certain way, admirable nomenclature is that which
was adopted in 1838 by the Registrar-General in his statistical reports. On
the other hand, he thinks that the nomenclature proposed by the Royal
College of Physicians of London is neither simple nor practical, and that
it does not fully satisfy scientific requirements. As instances of this he
mentions that tetanus, shaking palsy, and chorea are put down in it among
the functional diseases of the nervous system, and that paralysis is de-
scribed as a disease of the nerves apart from diseases of the brain and
spinal cord. Now, he says, if any fact is well established in the pathology
of the nervous system, it is this, that paralysis from disease of the peri-
pheral nerves is not only very rare, except in time of war, but, also, hardly
ever fatal.
He proposes, in the place of this classification, one which he has been in
the habit of using in the registration of cases which have come under his
care at the Regent's Park Hospital. It Avould occupy too much space if
it were given in detail; we therefore only mention the general headings :
1. General Neuroses. 2. Diseases of the Brain and its Membranes. 3.
Diseases of the Spinal Cord and its Membranes. 4. Diseases of the
1 878.] Althaus, Diseases of the Nervous System.
401
Cerebrospinal Nerves. 5. Special Forms of Paralysis. 6. Special Forms
of Anesthesia. 7. Affections of the Vaso-motor Nerves. The first three
classes are considered in the present volume, the remainder are to be dis-
cussed in a subsequent volume.
After presenting a rapid survey of the present state of the pathological
physiology of the nervous centres, the author proceeds to consider the
several diseases of the nervous system, taken separately, doing so in the
order in which he has found them numerically important.
By far the most frequent and fatal of the diseases of the nervous system
are convulsions, which caused, during the thirty years over which Dr.
Althaus's researches extend, more than three-quarters of a million of deaths
in England and Wales, or nearly one-half (47.84 per cent.) of the entire
number of deaths from all nervous disease. The author's tables, however,
show that there has been an uninterrupted fall in the mortality from con-
vulsions ever since registration was commenced, the difference between
the first and last periods of five years being as much as 18.78 per cent.
This result the author attributes to our methods of treating this condition.
Infants, of course, furnish by far the largest number of victims to convul-
sions, but we suspect that our readers will scarcely be prepared to hear
that out of 23,962 deaths which occurred in England and Wales from this
cause in 1847, 19,680 were of children in the first year of life, and 23,347
of children under five years of age. Sex, too, is not without its influence
in the production of convulsions, which Dr. Althaus's tables show to be
much more fatal to boys than to girls ; the mean percentage being 25 for
the former and only 20 for the latter. But these tables show, also, that
this influence, although still considerable, is in process of diminution. In
the remarks on the pathology of convulsions, Dr. Althaus shows that a
most intimate connection exists between convulsions and anaemia of the
brain.
Apoplexy is also the cause of a large number of deaths, no fewer than
twelve thousand persons dying annually in England and Wales of it. It
constitutes, the author says, after convulsions, the most fatal of all dis-
eases of the nervous system, carrying off year by year, with unerring cer-
tainty, more victims than either paralysis, epilepsy, or insanity. The
mortality from it is, however, very much less than that from convulsions,
as it constitutes only 16.36 per cent, of deaths from all nervous diseases.
It is essentially a disease of old age, although it appears to be of more
frequent occurrence in infants than is generally supposed. Thus, in the
year 1847, as many as 126 deaths occurred from it in infants in the first
year of life, and 229 in children under five years of age; while 1017
deaths occurred from it in persons between 70 and 74, and about 1500
from it in persons over 74 — a very large mortality when it is remembered
how few people are alive after 74. The results of the researches of Dr.
Lidell and of Dr. Hammond show a preponderance of the male over the
female sex as far as mortality from apoplexy is concerned, but the au-
thor's analysis of a very much larger number of cases proves that apo-
plexy is more fatal to females than to males to the extent of .17 per cent,
of the entire mortality from all causes. It is possible, however, as the
author himself admits, that apoplexy is of more frequent occurrence in
English women than in those of other countries, since they are, as a rule,
more addicted to habits of intemperance. But the rule which has just
been announced is not without exceptions, for the form of apoplexy to
which new-born infants are most liable is oftener met with in boys than
462
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[April
in girls. This is no doubt owing to the fact that in the former the head
is larger and more completely ossified than in the latter — a condition
which is very apt to cause a tedious labour, and, in many cases, to render
necessary the use of the forceps.
As the author defines apoplexy as the condition in which a person has
more or less suddenly lost his consciousness, sensibility, and mobility,
while respiration and the heart's action continue, he holds that it may be
produced by, 1, embolism of the cerebral arteries; 2, acute alcoholic in-
toxication; 3, acute intoxication by opium and other narcotic poisons;
4, sunstroke, as well as by hemorrhage, and a determination of blood to
the brain. He admits, however, that there is a form of sunstroke in which
death occurs from syncope, and believes that its true pathology consists in
paralysis first of the heat-regulating centre in the cervical cord, and after-
wards of the cardiac and vaso-motor centres in the medulla oblongata.
Adopting, it will be seen, the view of its nature which is generally held in
this country.
As it is not always easy to recognize the different forms of apoplexy, we
will quote what Dr. Althaus says, when discussing the differential diag-
nosis between cerebral hemorrhage and embolism : —
" In general, there is no initial decrease of temperature in softening, such as
we have seen to occur in cerebral hemorrhage ; or, if it should occur, it is much
less marked. Bourneville has shown that in many cases of softening soon after
the attack, the temperature rises suddenly to 102°, or even 104°; it then falls
again, reaches the normal average, and shows irregular oscillations. It some-
times remains stationary for a couple of days, or shows morning or evening
falls. In cerebral hemorrhage, on the other hand, the temperature, when it has
once reached 102°, does not go back to the physiological standard unless a fresh
effusion of blood should take place; and the oscillations arc more regular, and
occur in a narrower compass than in softening. After the temperature has been
stationary in softening for a more or less considerable time, it begins gradually to
rise, and reaches 103° and 104°; but towards the end it is not nearly so high as
in cerebral hemorrhage, Avhere it sometimes reaches 108°. After death there
may be a slight increase, but, as a rule, the temperature falls more rapidly than
it does in cerebral hemorrhage."
The symptoms of thrombosis of the cerebral arteries, which occasionally
occurs, resemble, to a certain extent, those presented by embolism, but
are usually more slowly developed and are preceded by premonitory symp-
toms indicating the gradual constriction and plugging of the artery.
These are headache, vertigo, stammering, impaired memory, numbness
and chilliness of one side of the body, local palsies — especially of the ocu-
lar muscles — and other symptoms which are generally thought to be
dependent upon softening of the brain. But the symptoms will of course
vary with the artery obstructed. Thrombosis of the cerebral sinuses is
accompanied by even less well-marked symptoms. The author mentions
as among the most common of these, when it occurs in children, rigidity
of the muscles of the neck, back, and extremities, nystagmus, strabismus,
and ptosis, which are soon followed by somnolence and coma. In adults
it is said to give rise to great depression and apathy, headache combined
Avith sickness and vomiting, alterations in the size of pupils, clonic con-
vulsions, and tremor of the limbs, and in some cases to congestion of the
external veins communicating with sinuses. But all these symptoms may
fail, for in a case under the writer's care, in which the diagnosis was con-
firmed by the post-mortem examination, the only evidence of cerebral
thrombosis was at first a slight diplopia. This led to an ophthalmoscopic
1878.] Althaus, Diseases of the Nervous System.
463
examination, when both disks were found to be swollen. In a few weeks
the patient became blind, and finally died — retaining, however, his con-
sciousness until a short time before his death.
There is perhaps no disease of the nervous system which is held in so
much horror by the laity as epilepsy. It does not, however, appear to be
the cause of a large mortality, for during the thirty-five years over which
the author's investigations extend, only .47 per cent, of the whole number
of deaths occurring in England and Wales are attributed to it. It is more
fatal to men than to women, although the difference is in this case unim-
portant. Dr. Althaus's figures show that it is very fatal in the first year
of life, but it is probable that some of the cases which are here included
under the head of epilepsy should properly be set down under that of con-
vulsions. This is the time of life, it will be remembered, when the latter
are most fatal. At all events the mortality is very slight in the second
year, and continues so until the tenth year, when it gradually rises, attain-
ing its maximum in the twentieth year of life. The liability to die from
this disease gradually diminishes as age advances.
The author recognizes three principal forms under which epilepsy pre-
sents itself. These are, of course, 1, epilepsia gravior; 2, epilepsia mi-
tior; 3, epileptic vertigo. In regard to the aura which generally precedes
the attack in the first variety, the author believes that 'it is "part and
parcel of the epileptic attack, and differing from the latter only in degree."
"This giddiness," he goes on to say, "is a lesser degree of coma, and
localized convulsions in the muscles of the wrist, a slighter degree of
general convulsions. We can only assume the aura to be peripheral in
those cases where injury of peripheral nerves, such as the sciatic or the
fifth, appears to give rise to epilepsy. The fact that an attack can some-
times be prevented during the aura by a powerful impression being made
upon certain peripheral parts, does not, by itself, speak for the peripheral
nature; for under such circumstances there is no interruption to any
peripheral excitement spreading towards the centre ; but, on the contrary,
reflex inhibition spreading from the centre towards the periphery."
It does not appear to be fully recognized as yet by the members of the
legal profession that patients, while suffering from epileptic vertigo, often
perform automatic acts, which are in most instances perfectly innocent
and harmless, but for which they are entirely irresponsible. Unprovoked
murders have been committed by individuals while in this condition, and
there is reason to fear that many have suffered the extreme penalty of the
law for offences of which they were morally innocent. The author dwells
at some length upon this form of epilepsy, and records several cases in
which automatic acts had been performed while in a state of unconscious-
ness by patients who had come under his observation.
The relation which chorea bears to rheumatism has been the subject of
much discussion of late years. By those who believe that the symptoms
of the former disease are wholly due to the impaction of minute emboli in
the smaller arteries of the brain, the connection is believed to be most
intimate. The author, on the other hand, believes that the embolic
theory of chorea is as yet unproven, and that it utterly fails to explain
those cases in which the symptoms of the disease supervene immediately
after fright or other mental emotions. He does not even consider the
presence of a murmur as a positive indication of the existence of endocar-
ditis, as it may be due either to anaemia or to the irregular action of the
cardiac muscles, which permits a certain amount of regurgitation by inter-
464
Reviews.
[April
fering with the closure of the auriculo-ventricular waives. Indeed, Dr.
Dickinson has rendered it probable that in these cases there may be, in
consequence of the irregularity of the heart's action, a deposition of fibrin
upon the valves, which may be mistaken for the effects of endocarditis.
The author's views on the pathology of chorea may be summed up as
follows : —
"1. In a large class of cases chorea is owing to the alteration in the composi-
tion of the blood, which is associated with rheumatic fever, and which is known
to affect the nervous centres as well as other organs. 2. Jit another large class
of cases chorea is produced by direct irritation of the nervous system, which is
either purely mental in its character, or partakes of a reflex character (chorea
gravidarum and after injury). 3. Endocarditis exists in the large majority of
cases of chorea; and is either pre-choreic, where the rheumatic influence has
to be accused, or post-choreic, where we assume it to be due to irregularity in the
action of the cardiac muscle ; but endocarditis cannot be considered a cause of
chorea. 4. Chorea is owing to hyperaemia of the territory of the middle cerebral
artery, and more particularly of the corpora striata. In cases which end favour-
ably, this hyperamiia does not proceed to the rupture of the bloodvessels ; but
in fatal cases effusion of blood and consequent injury to the surrounding tissue
take place. 5. A similar affection of the spinal cord, more particularly in the
region of the posterior horns, is generally associated with the cerebral changes ;
and where mental symptoms have been prominent during life, it is probable that
the cineritious structure of the convolutions of the brain has also been in a state
of hyperaemia.'
Chorea is not a fatal disease, since the author found it to be the cause
of only .10 per cent, of the deaths from nervous disease, and of only .012
per cent, of the deaths from all causes. His researches also show it to be
a little more than twice as fatal in girls as in boys.
Dr. Althaus subjects in the same way the statistics of the other diseases
of the brain and spinal cord to a careful analysis, arriving at results which
cannot fail to be interesting to the student of this department of our sci-
ence ; but unfortunately want of space prevents us from noticing in fur-
ther detail this most excellent work.
The author, although, as his name implies, a German, writes English in
such a way that his nativity might almost escape detection. He has, how-
ever, fallen into a curious mistake in regard to the word decubitus, which
means in our language the position which a patient assumes in bed. The
American or English reader who associates no other meaning with this
word, will scarcely understand such sentences as the following : " Thus
decubitus may kill in a variety of ways." " Acute decubitus is observed
not only in the sacrum, but also in the hips, knees, and ankles." They
will become intelligible enough to him when he learns that decubitus is the
German word for bedsore. J. H. H.
1878.]
Okth, Pathological Anatomy.
465
Art. XXIV. — A Compend of Diagnosis in Pathological Anatomy, ivith
Directions for making Post-mortem Examinations. By Dr. Johannes
Orth, First Assistant in Anatomy at the Pathological Institute in
Berlin. Translated by Frederick Cheever Shattuck, M.D., and
George Krans Sabine, M.D. Revised by Reginald Heber Fitz,
M.D., Assistant Professor of Pathological Anatomy in Harvard Uni-
versity. With numerous additions from MS. prepared by the Author.
8vo. pp. xxxvi., 440. New York: Hurd & Houghton, 1878.
Pathological histology, as the basis of pathological anatomy, although
one of the latest born of its departments, is after all that upon which true
scientific medicine most depends; and this fact, which has for years been
accepted on the continent of Europe, is now becoming fully recognized in
our chief medical centres, and must ere long be both understood and acted
upon by every intelligent physician in the land.
Indeed, when we come to attentively consider the subject, it is obvious
that around pathological anatomy as a centre revolves the whole circle of
the medical sciences, because, since the beginning of each departure from
health, the initial starting point of every malady, is one of those infinitely
various structural alterations, to which our systems are constantly liable,
it follows that, on the one hand, practical medicine and surgery with their
study of symptoms, and application of remedies (including therefore mate-
ria medica and chemistry), can only be securely founded upon an accurate
knowledge of the tissue changes which alone are the primary elements of
disease; and, on the other hand, since physicians have professionally no
concern with healthy human bodies, it is of course only by way of stand-
ards, according to which Ave can judge the structural alterations discovered
in the study of pathological anatomy, that the facts revealed by normal
anatomy and physiology are of any practical value to us merely as medical
men.
The book before us is the first work in our own language which points
out to the student of pathological anatomy a complete systematic course
for the combined macroscopic and microscopic examination of the various
organs, and for a consequent accurate diagnosis of the lesions which have
been the cause of death. Representing as it does the teachings of our
greatest living pathologist, Prof. Rudolph Virchow, to whom Dr. Orth has
for some time been first assistant in the Pathological Institute of Berlin,
and thus embodying the gathered experiences of nearly twoscore years as
to the best and most practical methods of investigation, it is a volume
which no scientific physician can afford to do without. This will be, we
think, amply proved by the outline of its contents, and occasional abstracts
we propose to make from its pages.
After a table of contents, which is invaluable as a guide to all the details
of the several parts and organs which it is desirable to investigate, the
manual appropriately commences with some admirable suggestions in
regard to the preliminaries, instruments, and appliances for performing
pathological autopsies, which are stated to differ from those made for me-
dico-legal purposes only in that during the latter everything which may
serve the ends of justice is treated with even greater accuracy and detail.
Among the preliminary arrangements we find it advised that autopsies
should be made by daylight, because yellow artificial light modifies the
natural colour of the parts. Indeed, the new Prussian regulations for foren-
466
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[April
sic physicians, which are generally followed throughout the vol nine, do
not allow an autopsy to be made by artificial light unless circumstances
are such that it cannot be postponed. The body should rest on a table
high enough to render much stooping unnecessary, and this should be
secured even in private houses, where we are obliged to improvise a suit-
able support by the aid of an old door, or some planks, sustained on the
backs of chairs.
In the list of instruments prescribed by the regulations we find besides
scalpels, forceps, hooks, saws, etc., a pair of callipers, a metre (or yard)
measure, a large graduated vessel for measuring fluids, scales with weights
up to ten pounds, a good magnifying glass, blue and red test-paper.
"The sharper the knife the better, and it is not to be held like a pen as in the
dissecting-room, but grasped firmly in the hand ; incisions should be begun with
the heel of the blade, not the point, and the knife swept along from the shoulder
rather than the wrist, thus making a long smooth cut. . . . Virchow affirms
' that a large cut, though made in the wrong place or direction, is as a rule pre-
ferable to one or many small cuts, which are correct in these respects.' It is also
very important that incisions should be smooth, as may be insured by avoiding
excessive pressure on the organ or part, and drawing the knife firmly and steadily
through it. This latter remark applies with especial force to the softer organs,
and above all to the brain, in connection with which Virchow says, ' better false
cuts if smooth than jagged ones which are correct.' "
In regard to microscopic investigation we are told that it is often con-
venient to have a microscope at hand for immediate use, though generally
it will be found better to take home anything which requires the use of
that instrument, and there examine it at leisure. Valentin's double knife
is recommended as almost indispensable for fresh specimens. In using
this knife care should be taken that the blades, which should be very sharp,
are as nearly parallel as possible, and if the organ to be examined is of lax
tissue, they should be more widely separated than if it is dense. Before
using it the instrument should be dipped in a mixture of alcohol two parts,
and water and glycerine, in equal proportions, one part, to prevent the
section from adhering to the blade and being torn. The knife after being
thus moistened should be held like a fiddle bow, and the anterior extremi-
ties of the blades laid on that portion of the organ from which it is desired
to obtain a section, and which should in some way be put upon the stretch.
The slice of tissue is then made by pushing the knife forward its whole
length, with moderate pressure downwards, and drawing it backwards
again if needful. Sections and teased-out specimens should always be
examined in indifferent fluids, such as aqueous humour, or serum, or half
per cent, common salt solution. Among reagents iodine, osmic acid, acetic
acid, caustic soda, and muriatic acid are recommended, and their use
described. Much, it is stated, can often be gained, even in the examina-
tion of fresh specimens, by the employment of various colouring matters.
Methyl-aniline is said to be very convenient on account of the rapidity
with which it acts, its aqueous solution of one-tenth of one per cent, stain-
ing nuclei of cells a beautiful blue colour in a few minutes ; its value is
much increased by the fact that it stains tissues which have undergone
amyloid degeneration of a bright red tint. Hematoxylin is also valuable
and much more permanent, except in the presence of an acid, the smallest
quantity of which will decompose it. The formula advised for Haematoxy-
lin is that of E. Klein, in which the solution is preserved by about fifteen
per cent, of alcohol. Carmine in the usual form is recommended, when
more time can be expended in the preparation of the specimens.
1878.]
Orth, Pathological Anatomy.
467
We next come to the directions for systematic inspection of the body,
including that required for medico-legal purposes, and that of new-born
children ; under this latter head we notice the convenient rule that, during
the last five months of foetal life, the length in centimetres is (about) five
times the number of the lunar month' which the child has reached in its
development.
After minute instructions in regard to the more common diseases of the
skin, hair, nails, etc., we find, on pp. 26-31, some excellent advice in re«-
gard to the diagnosis of external tumours, for example —
" Soft warts or moles when congenital are called mothers' marks (ncevi ma-
terni), and belong almost exclusively to the true skin. They are more or less
sharply elevated above the surface ; are seen on section to consist of soft gray tis-
sue, which is strongly contrasted with the structure of the skin ; extend for a
variable depth into the cutis, and sometimes into the subcutaneous tissue ; and are
covered by an epithelial layer which is but little if at all thicker than normal.
They are often pigmented, the pigment lying partly in the lower layers of epithe-
lial cells, but chiefly in the richly cellular connective tissues of which the mole is
composed. These formations are interesting chiefly from the frequency with
which sarcomatous tumours spring from them. . . . The so-called dermoid
cysts resemble wens closely, but are much more rare. They range from the size
of a walnut to that of a hen's egg, and consist of a sac containing a soft, yellowish,
greasy mass of fat, cholesterine, epidermis, etc. Sometimes hairs, or even more
[highly] organized structures, are found in them. The wall is not as in a wen a
simple fibrous investment, but contains all the elements of the outer skin — epider-
mis, cutis richly supplied with vessels, hair, and sebaceous glands. . . . The
formation of sebum predominates over that of epidermis — the reverse is the case
in wens — and hence a large cavity containing chiefly sebum, or a honey-like ruat-
ter, may nearly always be classed as a dermoid cyst. (Virchow.)"
Again, in regard to the very common fatty growths met with in all
parts of the body, our authors remark clearly and briefly —
" Lipomata (fatty tumours) are often met with on the skin, and are to be re-
garded as local hyperplasia? of the subcutaneous fat tissue. They are distinctly
lobulated ; the lobules are separated by vascular connective tissue, and the fat
cells are plainly visible to the naked eye. These tumours are more or less elevated
above the surface, and sometimes indeed are only connected with it by a small
pedicle (lipoma pendulum) . If the interstitial connective tissue be abundant and
dense, the tumour is harder, and white bands are seen running through it (lipo-
ma fibrosum or durum) ; if the tissue softens — this is more liable to occur at the
centre — the fat escapes from its limiting membrane, and a cavity is formed filled
with an oily mass. Telangiectasis is often associated with these tumours (lipoma
telangiectodes) ; this form is congenital. A remarkable formation of fatty tissue
often takes place about old hernial sacs."
"A growth of mucous tissue is sometimes found in lipomata, especially at the
centre (lipoma myxomatodes, or myxoma lipomatodes, according as either structure
predominates). The myxomatous portion is somewhat transparent, gelatinous,
and becomes white on the addition of acetic acid, as can be seen with the naked
eye. Under the microscope — a bit snapped off with the scissors will generally
answer the purpose — one sees a perfectly transparent substance, in which the
addition of acetic acid produces a filamentous or granular opacity, which does not
disappear on adding an excess of the reagent, and which contains a network of
star- and spindle-shaped cells with anastomosing processes."
From this extract, which is but a fair sample of the concise yet compre-
hensive manner in which almost every point in diagnosis is explained, our
readers can form an opinion of the extremely practical nature of the work,
and its great usefulness, not only to beginners, but equally to advanced
students in pathological anatomy. Especially is its value enhanced by
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[April
numerous important hints in differential diagnosis, such, for example, as the
following: "There is one point in regard to the distortion of the nose
which is of special importance. Lupus attacks first the anterior portion
(the soft parts and cartilages), whilst syphilis attacks the bone first, and
allows the bridge of the nose to sink in."
Among the few errors of omission and commission in this part of the
volume which have escaped the attention of author, translators, and re-
viser, and which should be corrected in the next edition, which we hope
will be soon called for, we notice the following on p. 66 : " Needle prepa-
rations of gummy tumours" should be explained to mean specimens pre-
pared by teasing out fragments of tissue with mounted needles ; and on p.
77, the illogical statement that the fact of the vascular network of a so-
called apoplectic cyst resembling the fibrous form of mucous tissue in the
umbilical cord "is a proof" that the neuroglia from which this vascular
network develops, is closely allied to mucous tissue, should be modified.
In regard to the interesting and important subject of cancer, our au-
thor follows, of course, Virchow and Rindfleisch in their doctrine, that
the diagnosis of carcinoma can be considered final only when it has been
demonstrated that the structure consists of masses of cells more or less
epithelioid in character, and lying in alveoli with fibrous walls ; although
we think the absence of any intercellular substance lying between the
individual cell elements which occupy each alveolus should be insisted on
as a part of this definition. We find the following excellent suggestions
concerning the recognition of supposed carcinomata.
"The cut surface is not uniform and homogeneous, but on close examination
is seen to present grayish- white, and often distinct retiform bands, which inclose
a white, or yellowish- white substance. An opaque and often milky fluid can be
scraped off with the knife ; and this juice the microscope shows to consist of
irregular angular cells of varying size, with large vesiculate nuclei and large
shining nucleoli (epithelioid cancer cells). This fluid varies greatly in quantity,
and there are hard cancers from which the cells cannot be squeezed out, and the
nature of which can only be determined by the aid of the microscope. Sections
of these show larger or smaller compact collections of cells, without intercellular
substance, in character similar to those above described, which are separated by
septa of variable width consisting of connective tissue — sometimes dense, some-
times looser, and rich in cells. The cells may be removed by firm brushing under
water with a camel's hair pencil, and the stroma thus brought into view."
The solution of that problem which sometimes proves so difficult not
only to novices, but also to microscopists who have long passed the period
of their novitiate, the diagnosis of sarcomata from carcinomata is efficiently
aided by the description above quoted, and that of the histological struc-
ture of the sarcomata given on pp. 33 and 34. In the next four pages the
peculiarities of colloid cancer, and of epithelioma, are minutely described.
In proceeding to the internal investigation of the cavities of the body,
it is advised that the head should be examined first, then the thorax, and
lastly the abdominal cavity, although the last of these is actually opened
before the second. If it is desirable in any particular case to examine
the spinal cord, this should be done first of all, partly to avoid turning the
body oftener than is absolutely necessary, but chiefly to render investiga-
tion of the brain and cord, which are so intimately related in physiological
function, as connected as possible. The soft parts are to be dissected
away from the spinous processes and arches of the vertebra?, which are
then to be cut away with a chisel or rachitome, and the spinal marrow
carefully and gently lifted out of its bed.
1878.]
0 r t h , Pathological Anatomy.
469
In opening the head the ordinary method is recommended of making an
incision through the soft parts over the vertex from one mastoid process to
the other, reflecting the scalp forward as far as the superciliary ridges, and
backward behind the external occipital protuberance, then incising the tem-
poral muscles and remaining soft parts on each side from the glabella to
the occipital protuberance, and finally sawing through the skull in this line.
Prof, Fitz suggests in this connection that, when it is desirable to avoid
any chance of disfiguring the corpse, this incision should be wedge-shaped,
the apices of the wedge being at the base of the mastoid process; and that
when the calvaria is returned to its place, it should be secured in proper
position by sutures passed through the cut edges of the temporal fascia
on each side. As any permission to make subsequent autopsies in a par-
ticular neighbourhood, especially in the rural districts, so much depends
upon the avoidance of the least apparent mutilation or disfigurement of
the body, we feel sure our readers will be grateful for this valuable hint.
When the dura mater is brought into view by the removal of the cal-
varia, its tension should be tested by attempting to lift up a fold of the
membrane near the apex of the frontal lobe, according to the following
simple rule. In the usual position of a body on the back, we should be
able to raise up a small fold, but if, on the one hand, a pretty large fold can
be thus lifted, the contents of the skull are diminished ; whilst, on the other
hand, if no fold at all can be raised, they are increased, as occurs in hydro-
cephalus, cerebral hemorrhage, tumour, abscess, etc.
The appearances indicative of meningeal hemorrhage, inflammation,
etc., are carefully pointed out, but must not long detain us, although we
cannot resist quoting the following admirable paragraph on tubercular
meningitis on p. 63.
" The most important changes which are found in the pia mater of the base,
are those which are due to arachnitis tuberculosa, and from the fact that they
are generally confined to the base, this disease has- received the name of basilar
meningitis. The anatomical appearances consist in the presence of collections of
a yellowish gelatinous substance of varying consistency in the network of the
pia, within the circle of Willis, and especially about the optic commissure ; the
exudation may also extend far into the fissure of Sylvius. The diagnosis is con-
firmed by the discovery of minute miliary tubercles, which seem to follow the
course of the bloodvessels, and are most abundant on the under surface of the
frontal lobes, or on the island of Reil. The tubercles may also be met with in
the connective tissue of the pia apart from any vessels. For microscopical examina-
tion a small bit should be cut away from [out of?] the pia, and carefully separated
from the surface of the brain with the aid of a stream of water, and then the bits
of cerebral substance which still adhere to it are to be removed under water Avith
a camel's hair brush. The tubercles may now be seen in the walls of the vessels
with the naked eye, and when examined in water, under the microscope, appear
as round-celled fusiform swellings of the adventitia. The nuclei are rendered
more distinct by acetic acid, and the preparation may be readily stained. Giant
cells are never found in these tubercles."
It is well known that the most common tumours of the brain substance,
which is next examined, are the sarcomata and glio-sarcomata, but the
diagnosis of these growths from tubercular nodules, erroneously denomi-
nated solitary tubercles, and from syphilitic gummata, is often attended
with the greatest difficulty because the sarcomata are so apt to undergo
fatty degeneration. Dr. Orth states, however, that a growth which is com-
posed of a gray and transparent or tough and fibrous ground work, with
numerous yellow and homogeneous masses scattered through it — and
especially if these masses are relatively dense— may be regarded as of
470
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[April
syphilitic origin. In regard to the differential diagnosis between tubercu-
lar nodules and gummata, he informs us that the most distinctive charac-
teristic of the former is the presence of gray submiliary tubercles, in the
grayish transparent zone, which surrounds the yellow and cheesy centre ;
these miliary tubercles are easily isolated with the aid of needles, and
often contain enormous giant cells. Tubercles again are more entirely
and uniformly caseous than gummata, the cheesy portions of which are
either surrounded or penetrated by more strongly marked zones of tissue,
of varying consistency. Lastly, the larger tubercles show central soften-
ing much oftener than gummata, although the circumjacent cerebral sub-
stance is more liable to softening in syphilis than in tuberculosis.
After full and elaborate instructions for examination of the brain, both
in the ordinary mode and by Meynert's method, our authors proceed to
the investigation of the nose, eyes, and ears. The growing importance of
ophthalmological researches, which are too often neglected for want of
knowledge upon the part of the operator of how to accomplish his object
without disfiguring the corpse, leads us to quote the folloAving advice.
The condition of the retina and choroid can be easily determined —
" by removing the roof of the orbit, with the mallet and chisel, from the inside of
the skull; the orbital fatty tissue and the muscles are then to be excised, and the
globe to be drawn backwards, when the posterior half should be cut away with
the scissors. The anterior portion of the globe, which is left behind [and in
front?], may be kept in place by plugging the orbit, and thus all deformity be
avoided. If one does not happen to have a mallet and chisel at disposal, the bone
scissors generally serves the same purpose."
There is much that is worthy of careful study in regard to the walls of
the chest and abdomen, and the contents of the latter, although we ob-
serve on p. 95 the excuse for classing " simple hypertrophy or pure adenoma
of the breast under cancer," viz., "for the reason that transition forms
occupying an intermediate position between the two are sometimes found,"
is diaphanous to excess. On the same principle all animals might be
"classed under" vegetables, viz., "for the reason that transition forms
occupying an intermediate position between the two are sometimes found."
We next come to the important step of opening the thorax. To remove the
anterior wall of the chest the cartilages are to be divided close to their costal
insertions, any escape of gas being looked for at the first cut, if there is sus-
picion of pneumothorax. A lighted match held over the opening will either
flare up or be extinguished, if gas is present, and its escape can thus be de-
monstrated to lookers-on. If the cartilages are calcified, divide the ribs
themselves with a saw or bone nippers. The clavicles are then to be dis-
articulated from the sternum by semilunar incisions, and the judicious ad-
vice is given that " in the latter part of these incisions the handle of the
knife is to be somewhat depressed backwards" (i. e. towards the spine of the
corpse as it lies upon its back), " to avoid the lower and inner prominence of
the articular surface of the clavicles." The subjacent cartilage of the first rib
is then to be incised carefully to avoid injury to the great vessels beneath,
after which the attachments of the diaphragm to the false ribs and ensi-
form cartilage are to be divided, and the sternum raised from below, the
mediastinum being separated from the bone by cautious transverse cuts.
Next, the contents of the mediastinum, the pericardium and its liquid
contents, and then the heart itself, are to be investigated. In regard to
this latter organ, we find the useful suggestion that " the formation of the
apex constitutes a good indication of the presence or absence of enlarge-
1878.]
Okth, Pathological Anatomy.
471
ment of the right side. In the normal heart the apex is formed solely by
the left ventricle ; but when the right ventricle shares in its formation, an
enlargement has taken place. A depression of greater or less depth is
sometimes met with between the apices of the ventricles, as a congenital
deviation from the normal form." After inspection, the heart should be
opened before removal from the body, incisions (which are minutely de-
scribed) being made into its anterior surface on each side of the septum,
in order to bring into view the cavities of the right and left heart. At this
point in the examination changes in the blood are considered, and the
varieties in its coagulation, colour, number of red and of white corpuscles,
etc., observed. Scoffers at the germ theory of disease, and at the doctrine
that organic entities may be the causes of constitutional maladies in the
human organism, will doubtless find food for profitable reflection in the
following statements : —
' ' Of all the modifications which the blood undergoes, the least understood, and
at the same time the most important, is unquestionably that which is due to an
admixture with low organisms. Recent researches leave no doubt whatever that
in some diseases the blood contains during life, though to a far higher degree
after death, certain low forms of animal or vegetable life.1 Those organisms
which have a thoroughly characteristic appearance can be detected without any
great difficulty with very high powers, provided that the layer of blood which is
examined be very thin, or that the red corpuscles have been destroyed with acetic
acid or alkalies. . The number of diseases in which these organisms are found is
small. During the paroxysms of relapsing fever the blood contains delicate spiral
thread-like bodies (spirilla), which move by turning in the direction of their
axes (?), and disappear after death. In anthrax or malignant pustule, a rare
affection in the human subject, the blood contains small rod-like bacteridia, which
are often joined together as long serpentine threads. These are, indeed, not
constant, but may be replaced by exceedingly minute spherical bodies (micro-
cocci), the detection of which requires very high .powers. They can easily be
distinguished from the rod-like bacteria seen transversely by gently tapping on
the cover ghiss, and thus causing movement in the fluid If, there-
fore, chains of equally sized spherules are found in the blood, they can be diag-
nosticated as micrococci with a certainty which is somewhat proportional to their
numbers. The most characteristic form in which the micrococci occur, is that of
large collections or groups, in which the separate granules preserve a uniform
size, and a uniform distance from each other." (pp. 118, 119.)
It is worthy of note in this connection, that on p. 24 the positive asser-
tion is made that the gray coating of wounds affected with hospital gan-
grene is made up —
' ' chiefly of micrococci (minute spherical bodies, either aggregated in masses or
strung together like beads on a rosary, and characterized by uniformity in size
and a peculiar lustre), and bacteria (staff-like bodies of various lengths, some-
times darting and wriggling about, sometimes strung together in chains or col-
lected in masses, in which latter case they are distinguished from collections of
micrococci by the presence of a transparent and gelatinous substance in consider-
able amount). To bring out these bodies clearly it is advisable to add to the
microscopical preparation a little dilute caustic potash, which dissolves most
organic structures, but does not affect these organisms."
Dr. Orth states that many authorities refer to the presence of parasites,
not only in the serum of the blood, as has been described above, but also
in the cell elements. Whilst this is probable as regards the leucocytes, he
1 [These " recent researches" in Germany were anticipated in their results by observa-
tions laid before the readers of this Journal nearly ten years since. Vide, amongst
others, a paper entitled "Experiments showing the occurrence of Vegetable Organisms
in Human Blood," in the July No. of 1868, p. 291.1
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[April
thinks that crenation of the red corpuscles, especially when seen edgewise,
may have often misled observers who consider the granular appearance as
due to vegetable organisms, a view which is no doubt correct. Micro-
cocci, he concludes, " have been found in the blood in the most various
diseases, but chiefly in septicaemia, puerperal diseases, diphtheritis, etc.
They are, however, not constant even in these affections."
On p. 123, the use of osmic acid solution in distinguishing the oil
globules of fatty degeneration (of the heart, etc.), might with propriety be
advised.
We should be glad, did space permit, to consider in detail the further
admirable directions for examination of the heart and lungs, which must
commend themselves to every one who feels the need of a guide (as every
practitioner must do occasionally, at least) to the thorough and exhaustive
investigation of the important organs in the thoracic cavity. But we must
content ourselves by urgently recommending every physician who has
either expectation or hope of enjoying the privilege of making a single
autopsy during the next decade to carefully peruse this volume.
We will briefly notice our author's treatment of a few of those mooted
points upon which, as he mentions in his preface, additional light has been
thrown by recent investigations.
The doctrine of the non-identity of phthisis and tuberculosis, so posi-
tively taught a few years since by Niemeyer and his followers, seems to be
contested with renewed acrimony at the present day, and we sought with
considerable interest for Dr. Orth's exposition of the latest views in regard
to it. Very adroitly, however, after describing the actual conditions of
the lungs in tuberculosis, broncho-pneumonia, and fibroid phthisis, he
eludes the chief question in the following paragraph : —
"We have now described all the processes that are comprised in what is gene-
rally known as pulmonary consumption or phthisis. It would lie a great mistake
to suppose that any one of these processes singly brings about all the changes that
are found in a case of phthisis ; as a rule, several or many processes are coexistent,
and this accounts for the great variety of appearance in phthisical lungs, of which
scarcely any two are to be found alike. For this reason, we cannot undertake to
describe the manifold appearances to which combinations of the processes may
give rise, but hope that what has been already said will enable the reader to dis-
tinguish the several processes from one another, and thus understand their sum.
We would only repeat that many cases which were at first of a purely inflamma-
tory nature, are subsequently complicated with tuberculosis, which also takes its
part in the destruction of tissue. The condition receives its name from the pro-
cess which may happen to be predominant, and we speak of inflammatory or
pneumonic phthisis when inflammation and caseation are chiefly prominent, or of
tubercular phthisis when the reverse of this is the case."
In the present lamentably unsettled state of this problem, perhaps no
safer suggestions than these could be offered, but we earnestly trust that
further investigations will, before many years, unveil that mystery which
now surrounds the relations, if there be any existing, between the exuda-
tion cell of pneumonia and the tubercle corpuscle of tuberculosis.
In applying the hydrostatic test to the lungs of new-born infants in
medico-legal cases, the following minute instructions, quoted from the
official " Regulations," are well worthy of observance, as comprising the
lessons of most recent experience. After opening the neck and tightly
ligating the trachea above the sternum, this bone and the costal carti-
lages are to be removed in the usual way. " The trachea is then to be
divided above the ligature, and the lower portion removed from the body,
1878.]
0 R T h , Pathological Anatomy.
473
together with all the thoracic organs. The thymus glands and heart are
next to be dissected off with care, the interior of the latter may now be
examined, and. the lung is then to be placed in a spacious vessel, tilled
with fresh cold water, to see whether it will float. The lower portion of
the trachea and the primary bronchi are- then to be laid open, and the
character of tkeir contents accurately noted," etc.
The subjects of leucaemia and pseudo-leucaemia, which have of late at-
tracted so much attention in the medical world, are treated of in the
usual concise yet clear manner, and the pathological changes met with in
the spleen and lymphatic glands, in these affections, briefly described.
No positive rule is given by which to distinguish histologically between
the alterations of the splenic pulp and follicles, in true and false leuco-
cythaemia, it being expressly stated that malignant lympho-sarcomatous
growths -in the latter malady cause the follicles to be universally enlarged
to a varying degree, sometimes to the size of a cherry or walnut, " and
the spleen may then greatly resemble that variety of leucamric spleen in
which the follicles as well as the pulp are hyperplastic." The diagnosis,
however, is to be made by observing that the number of the white blood
corpuscles is not increased, although our authors neglect to mention that
since the red disks are often seriously diminished in number, this changed
proportion between the two kinds of corpuscles might give rise to an
incorrect diagnosis of true leucocythaemia, unless the actual number of red
disks per cubic millimetre is determined by means of Hayem's or Malas-
sez's apparatus.
Respecting the cutis cerea of Addison's disease, and its association with
pathological changes in the supra-renal capsules, it is stated that the
bronzed hue is least constant in cancerous, most common in cheesy de-
generation of the capsules. It is much to be regretted that the difficulty
of securing specimens of this rare affection still renders the theory that
this cutaneous discoloration is due to alterations in the neighbouring sym-
pathetic nerves composing the solar plexus and the semilunar ganglia
only a plausible hypothesis.
In the excellent section upon the kidney, the development of purulent
interstitial nephritis is attributed first to the production of metastatic ab-
scesses by septic emboli, and second to the direct effect of the presence of
low organisms (bacteria, micrococci, etc.), which have Avandered upward
from the bladder, along the ureters, pelves of the kidneys, and the urinif-
erous tubules. In this affection the abscesses appear on the surface as
minute yellow points of the size of a millet grain, and are arranged in
small groups ; but on making a section, these little abscesses may often,
not always, be traced through the cortical into the pyramidal portion.
Microscopic examination, according to Dr. Orth, " shows that the urinary
tubules are completely plugged and even distended with micrococci, that
the epithelial cells, not only of these but of the neighbouring tubules, are
fatty degenerated, and that only finally a zone of interstitial suppuration
surrounds these centres." This disease is almost always accompanied by
inflammatory and often actually diphtheritic processes in the bladder,
occurring as causal complications, and it was in it that Klebs first recog-
nized the constant appearance of low vegetable organisms, and attributed
to them their true causative relation, which has not, in this country at
least, received the attention which it merits. The assertion on p. 216,
that tube casts in tubules of the kidney " sometimes undergo amyloid
No. CL April 1878. 31
474
Reviews.
[April
degeneration," is unproved, and we think it much more probable that the
amyloid substance itself forms the tube cast.
The pathological conditions of the uterus after death from puerperal
fever are in like manner considered by Dr. Orth to depend on infection
with, and propagation of, low vegetable organisms (bacteria and micro-
cocci). When the presence of these agents is confined to the mucous
membrane, it is manifested by a diphtheritic inflammation (endometritis
diphtheritica). It presents a gray, grayish-yellow, or grayish-white mass,
containing innumerable colonies of micrococci, and also an infiltration of
the mucous membrane itself, as may easily be seen by making incisions
into that structure perpendicularly to its surface. This diphtheritic pro-
cess " usually takes its origin in the lacerations of the cervical portion, or
in the place where the placenta was attached, both of which afford par-
ticularly favourable conditions for infection. In many cases the morbid
changes extend deeply into the uterine tissue, and both bloodvessels and
lymphatics are found to contain soft, crumbly, yellowish -red thrombi, with
colonies of micrococci, and to have become actively inflamed." Obviously
these results of microscopic investigation, which seem to be considered as
unquestionable facts by our authors, both explain the hitherto inexplicable
infectiousness of puerperal fever, and suggest simple but efficient modes of
attaining its complete prophylaxis.
On p. 262 in the declaration that "the processes which extend from the
uterus (to the parametrium and broad ligaments) are essentially puerperal
affections," the words "chiefly" or "generally" should be substituted for
"essentially;" and the statement on p. 409 that "variation in the number
of bones frequently occurs, especially in the form of supernumerary joints
in the fingers and toes, or of supernumerary fingers or toes," is quite at
variance with the experience of most practitioners, at least in America.
But these and a few other blemishes mentioned above are of very minor
importance, and we must offer our hearty thanks to the translators and to
Prof. Fitz for presenting to us this invaluable manual in such good, clear,
readable English, free from the awkward Teutonic words, phrases, and
idioms which have so seriously impaired the value of some similar volumes,
and rendered them in portions absolutely incomprehensible to medical men
who were not also students of the German tongue. Dr. Fitz modestly
informs us that " whatever may have been sacrificed in style has been (so
sacrificed ?) for the sake of expressing the authors' views as exactly and
concisely as possible. A correct translation has been deemed of greater
importance than an elegant one." We think, however, that in this book
clearness and accuracy have been, with a few rare exceptions, most hap-
pily combined with excellence or even elegance of diction.
The work is handsomely printed on fine paper, with large clear type,
and in its mechanical execution fully sustains the high reputation of the
well-known book publishers to whom we are indebted for its production.
J. G. R,
1878.] 475
«
ANALYTICAL AND BIBLIOGRAPHICAL NOTICES.
Art. XXV. — Medico- Chirurgical Transactions. Published by the Royal
Medical and Chirurgical Society of London. Second series. Volume the
Forty-second. 8vo. pp. lxviii., 335. London: Longmans, Green, Reader, and
Dyer, 1877.
This volume comes to us in the style of its predecessors, and full of valuable
information. It contains twenty-three papers, many of which have been noticed
at length heretofore in the pages of this Journal, or in the Monthly Abstract.
We will, therefore, proceed to examine only those, analyses of which have not
already been laid before our readers. And the first is a Resection of the tarsal
bones for double congenital talipes equino-varus ; by Mr. Davies Collet.
The patient, aged twelve years, was admitted into Guy's Hospital, having
congenital deformity of both feet. When four years of age some of the
tendons were divided, but without any beneficial result ; since then he had not
been under any treatment whatever. On the 12th of October, the boy being
in good condition, chloroform being administered, and an Esmarch bandage
being applied, an incision three inches long was made along the outer border of
the left foot from the middle of the os calcis to the middle of the fifth metatarsal
bone, and from the centre of this another incision two inches long was made
transversely across part of the dorsum, dividing the tendons of the peroneus
longus and brevis and the extensor brevis dioitorum. The cuboid bone was now re-
moved, and the large processes of the os calcis were removed by a saw in a plane
looking forwards, outwards, and upwards. The three cuneiform bones were then
removed, and a large part of the scaphoid and a part of the head of the astragalus
were excavated. Then the articular cartilage from the base of the two outer
metatarsal bones was removed.
Antiseptic spray was used during the operation and at each dressing after-
wards. There was some oozing, which was controlled by the use of a sponge
soaked in carbolic lotion, which was kept in its place for a week after the
operation.
On the 23d of November, the left foot being nearly healed, the right one was
operated on. The bones (tarsal) being soft were pared away without the use of
the saw, the parts removed being similar to those of the right foot. There was
but little discharge, and no burrowing of pus. Each foot was kept in position by
a back splint extending from the middle of the thigh to within four inches of the
heel. To the distal end of this was fastened a transverse bar of wood, terminat-
ing on either side in short upright bars, to which the fore part of the foot was
attached by means of strapping.
On the 1st of January, the patient was being wheeled about in a chair.
In less than ten weeks from the second operation the wounds were quite healed,
and the splints and dressing were left off. The feet were now short for a boy of
his age, and the heel projected somewhat backwards. The boy could walk well,
treading upon the entire sole of each foot. The movement of the toes was per-
fect. The September following the boy walked eleven miles with perfect
comfort.
476 Bibliographical Notices. [April
From this operation and its subsequent successful treatment, Mr. Davies Colley
suggests the following points : —
"1. It is not necessary to divide the tendo Achillis before the resection, and
perhaps not at all.
" 2. Esmarch's bandage is of good use, rendering the tissues bloodless at the time
of operating.
"3. It is better to begin by removing the cuboid bone, and then remove such
portion of the adjacent bone as may be necessary to coadjust the part without the
use of force.
" 4. That the dangers of the operation are much diminished by the careful use
of antiseptic precautions.
" 5. The employment of the splint described facilitates very much the main-
tenance of the foot in good position, and renders the charge of dressing a simple
and almost painless proceeding."
Mr. R. Clement Lucas narrates the history of his case (aged 56) of removal
of a silver tracheotomy tube from the left bronchus, with recovery of the patient,
and draws attention to the following points : —
" 1 . That in a person who has worn a tracheotomy tube for many years, a foreign
body may become lodged in a bronchus without causing any great difficulty in
breathing, and without exciting any grave symptoms of irritation, for a consider-
able period.
" 2. That instruments may be freely introduced into the trachea in such cases
without fear of exciting serious bronchial inflammation.
" 3. That if a wire be used as a hook, it is very important that it should be of
soft metal, lest it should become immovably fixed. The difficulties experienced
in removing this tube were due in a good measure to a lack of proper forceps.
The forceps used for the removal of foreign bodies in the trachea or bronchi
should have blades which are small, light, and narrow, and about the length and
width of those used for the urethra. They should be slightly curved throughout,
but near the extremity of the handle the curve should be suddenly increased, the
object being to allow the operator to work beneath the projection of the chin.
The handles should cross slightly, so that the blades may be opened to a con-
siderable distance by a slight separation of the handles."
The next case is one of all but universal paralysis in a child, following ex-
posure to heat, with complete recovery; reported by James Andrews, M.D.,
and Dyce Duckworth, M.D., and we record it at length as one of more than
usual interest.
The child, aged 2j years, was brought to St. Bartholomew's Hospital on the
28th July, j 876. She lay helpless and incapable of movement in her mother's
arms. She was small and pallid, somewhat rickety, but fairly nourished.
On admission the face was a little flushed. The pupils were large and equal.
Tongue clean and red. She was quite conscious, and could speak as well as most
children of her age. Respiratory movement was mainly abdominal, jerky, and
irregular, about fifty-six per minute. The chest was everywhere resonant, and
the breathing- sounds weak. The position of the heart was normal, the sounds
clear, and the pulse 156 per minute, regular and compressible. The abdomen
was natural, save that the liver was an inch below the ribs on the right side.
Axillary temperature, 102.2° F.
She had complete loss of motor power both in legs and arms. She could move
the left scapula, but not the right ; could not raise her head from the pillow, nor
could she support it when held up, but rotation from side to side was possible
while she was in the recumbent position. There appeared to be anaesthesia of all
the parts affected with motor paralysis. She sometimes cried when one of the
toes was pinched hard. The muscles of all the limbs were extremely soft, wasted,
and flabby. In the legs a strong faradic electric current excited only slight
1878.]
Medico-Chirurgical Transactions.
477
reflex movements, but no muscles responded directly to* this stimulus in any
of the extremities.
The child lay on her back, and passed both feces and urine involuntarily, the
bowels being frequently moved. No^ urine could be saved for examination.
There was troublesome spasmodic cough, especially in the morning. Her appetite
was good, and there was no sickness.
Her history was this : She was born in America, of Irish parents, and was a
healthy child until her present illness began. While travelling by rail to New
York, in very hot weather, on the 23d June, 1876, the child complained of severe
headache, and was very ill. The same night she had pain all over her, was sick,
delirious, and very thirsty. During the following week she got better. She had
no loss of power, and could walk about. On the 1st July, while walking
on the wharf, before embarking, during a very hot day, the child fell on her
knees, and suddenly lost all power over her limbs. There was no loss of con-
sciousness. The same evening she was delirious, and had no control of the
sphincters. On the voyage she slept a great deal, was frequently delirious, and
took very little food. She had diarrhoea, but was not sea-sick.
On admission into the hospital she was placed on light diet, with milk and
arrow-root. Half a drachm each of cod-liver oil and syrup of phosphate of iron
was ordered three times a day. Some meat was soon after added to the diet.
In five days it was noted that no change had taken place in the child's condition.
No sickness and no deliriousness had occurred. A strong faradic current pro-
duced only slight muscular contractions in the arms, none in the legs. The
motions and urine were passed involuntarily, but some of the urine was obtained
and found to be devoid of albumen.
On the 2d of August, at the suggestion of Dr. Gee, one-third of a grain of
the extract of belladonna was given thrice daily, and a strip of belladonna plaster
was placed clown the whole length of the spine. The iron and cod-liver oil were
continued, and two ounces of port wine were added.
Faradization to the limbs was practised daily. On the following day the
tongue was clean and moist, the pupils somewhat dilated, and the cough was
more frequent. The respiration and pulse were quickened, and the temperature
had risen from 92° to 102°. The urine contained abundance of lithates. The
chest and abdomen were covered with a scarlet erythematous rash, which faded on
pressure. The same night the temperature rose to 103.6°. The next day the
pupils were widely dilated, the rash had extended to the neck and thighs, and
was fading on the chest and abdomen.
On the fourth day of the belladonna treatment it was noted that she could
move the left hand a little. She took nourishment, and slept well. The rash
extended to the head, and some redness extended over the sacrum. The bella-
donna was now increased to one and a third grains in the twenty-four hours ; and
in the evening, at 10 o'clock, on the fourth day of the belladonna treatment, the
temperature reached 104.5° — the highest point it attained during her illness.
Two days afterwards the temperature fell to 101.3°.
The next day a marked increase of power was noted in the left arm. She
was able to raise it to her mouth, and feed herself; there was also increased sen-
sibility in the left thigh. In a few days there was commencing power in the
right arm and leg, but there was no control as yet over the sphincters. The tem-
perature rose about one degree each evening, and reached 101°.
On the 12th August, sixteen days after admission, the child could raise both
hands over her head, and feed herself; there was increasing power in the right
leg, and sensibility in both legs. The pupils continued fully influenced by the
478
Bibliographical Notices.
[April
belladonna, but the tongue never became dry. The temperature varied from
99.4° to 100.6°.
On the twentieth day she was first able to control both sphincters. A powerful
faradic current only caused very slight muscular contraction in the limbs, and on
the twenty-fourth day stronger response was noted equal in the arms, but more
marked in the right leg.
After being employed for twenty-one days, and on the twenty-fifth day from
admission, the belladonna was omitted. Little improvement took place during
the following week. She could put one foot in front of the other when held up.
When lying down she was unable to crawl.
On the 29th of August her pulse was 156 ; respiration 44 ; and temperature
100.6°. The urine natural.
A drachm of the syrup of phosphate of iron and lime with one minim of liquor
strychnia? was ordered thrice daily. On the 5th of September she was not so
well. Her face was pale and puffy. The urine was "smoky," and contained
one-tenth of albumen, also granular casts and blood-disks. The pulse was 76,
and irregular ; respiration 28 ; and the temperature was observed to be normal for
the first time. In two days the pulse was more irregular, and the amount of
albumen in the urine was larger. No pyrexia. Some sickness occurred at times.
On the 14th of September, ten days after the albuminuria was noted, there
was only a trace of albumen in the urine, and the child could stand erect with a
little assistance. The ophthalmoscope revealed nothing abnormal.
On the 10th of October, seventy-five days after admission to the hospital, she
could stand and walk by herself around her bed. She gradually improved, and
three months from the date of admission she was in good general health, and had
perfect use of all her limbs and sphincters.
This case, the writers add, was one of profound nervous exhaustion.
The first symptoms of amendment were observed on the fourth day after taking
belladonna, and gradual improvement ensued both in recovery of sensory and
motor functions. The muscles were regularly stimulated with powerful faradic
currents for several weeks till active response took place, and strychnia was given
in small doses at a late period. It is added that cold affusion in the early period
of such an attack would probably avert or at least tend to reduce the severity
of the paralytic sequela?. W. S. F.
Art. XXVI. — Pneumono-Dynamics . By G. M. Garland, M.D., Assistant in
Physiology, Medical Department, Harvard University. 8vo. pp. xi., 155.
New York: Hurd & Houghton, 1878.
The title of this pamphlet is by no means sufficiently descriptive of its object.
The author states on page 3, that his intention is "to give a description of the
true curve of flatness" (produced by pleuritic effusion), " to teach the proper way
to search for it, to contribute certain experiments, which seem to throw some
light upon the origin of the curve, and, finally, to discuss the diagnostic value of
this much disputed symptom." While not at present denving that pneumono-
dynamics may have something to do with the explanation of the causes which pro-
duce this curve, we think a book so entitled would be the last place in the world
in which one would be apt to expect an account of the physical signs of pleurisy.
Dr. Garland prefaces his work by certain definitions of the terms employed in
his argument, which, though true in the main, are not remarkable for conciseness,
or accuracy of expression. But apart from this, Dr. G. has really presented to
1878.]
Garland, Pneunrono-dyna.mics.
479
us a contribution to scientific medicine which deserves the highest praise for in-
genuity and logical reasoning. We cannot help thinking, however, that his data
are hardly yet sufficient for the extended deductions which he has drawn from
them, but more of this directly.
Dr. Garland commences his essay by referring to the great diversity of opinions
which have prevailed concerning the direction and form of the line of demarcation
between pulmonary resonance and the flatness caused by pleural effusion, and then
quotes several cases reported by Prof. Ellis, of Boston, in which this line is de-
scribed as a curve, "which begins lowest behind, advances upwards and forwards
in a letter S curve to the axillary region, whence it proceeds in a straight decline
to the sternum." It is in the defence of this curve, with explanation and demon-
stration of the causes which produce it, that the book before us is mainly con-
cerned.
After laying down a number of rules, the proper observance of which is neces-
sary in order to detect this curve, the author then proceeds to detail in Chapter
II. his four experiments upon dogs. These experiments consist in the introduction
of various substances into the pleural sac of these animals, substances such as
glue, plaster of Paris, and cacao butter, which can be introduced while fluid, and
subsequently harden and preserve the form attained in the liquid state. When
these injections were made in the upright position, the main points that he noted
were, that the line of flatness obtained upon percussing the chest corresponded
with the superior margin of the hardened injection, and that this line was always
a curve, no matter what the position of the animal ; that the lung was diminished
in volume, but preserved its symmetry throughout ; that the lower part of the
lung was not compressed to an airless condition, and did not plunge into the fluid,
the former rather appearing to rest upon the latter ; no injection was present
between the chest wall and the lung, exeept the merest little ridge, which never
exceeded half an inch in height ; the inferior surface of the model was concave
in small injections, and corresponded to the arched "upper surface of the diaphragm.
When the dogs were injected in the oblique or horizontal position, he states that
he has noticed that there was still the same curved line, and that in all the casts,
there was one constant phenomenon, viz., the supporting of large bodies of fluid
above their hydrostatic level. Recognizing this condition as analogous to that
which must necessarily obtain in the case of effusions into the human pleura, un-
complicated by lung affections or adhesions, if the letter S curve is admitted as
the normal expression of the line of flatness, Dr. Garland then, in Chapter III.,
seeks its explanation in a series of experiments made upon elastic bodies in in-
closed spaces.
This chapter is decidedly the best in the book, and is a model of ingenuity in
the conception of his experiments, and in the logic with which his deductions are
drawn. We would like to transcribe the entire chapter, did not its length prevent.
We are also struck with the accuracy and preciseness of expression employed,
very different, indeed, from the looseness of phraseology employed in his "Intro-
duction." While admitting, however, the accuracy of his experiments, and the
truth of the statement on p. 43, that "the principles thus far developed are of
universal application to retractile bodies inclosed in firm walls," we must beg to
differ from the following clause, that these principles ' ' hence may be, with pro-
priety, applied to the retractile lung in the thorax." We need scarcely observe
that this method of reasoning is open to several objections, not the least of which
is the want of analogy between the rigid immovable walls of the glass flask em -
ployed in his experiments, and the elastic, movable, and moving walls of the
thorax.
In Chap. IV. Dr. Garland considers the analogy between dogs' lungs and
480
Bibliographical Notices.
[April
elastic bodies in inclosed spaces, and here draws the conclusion that the agent
which is the cause of this distribution of fluid above its hydrostatic level is the
negative pressure exerted by the elasticity of the lung. The remaining eleven
chapters are occupied with a general discussion of the subject in its various forms.
In Chap. XVI., as a summary of his work, he presents the following conclu-
sions : — ■
I. That the letter S curve of flatness was first accurately described and traced
through its various modifications by Prof. Calvin Ellis, of 'Boston.
II. That the letter S curve can be traced only in the erect position, and when
the play of the lung is not hampered by adhesions ; and that its persistence
throughout the various stages of an effusion indicates the absence of adhesions in
the lower part of the chest.
III. That the letter S curve of flatness corresponds in shape to the lower border
of the lung, and in position to the line of apposition between the lower border of
the lung and the upper border of the effusion.
IV. That the letter S curve is pathognomonic of a fluid effusion in the pleural
cavity, but that it is impossible to judge from any variations in the curve as to the
nature of the fluid present.
V. That the dull triangle which I have described corresponds to the posterior
inferior part of the lung, and that this portion of the lung is not, in the erect
position, separated from the chest wall by effusion until the amount of fluid has
become relatively very large.
VI. That a recognition of the dull triangle is very important for the detection
of the curve of flatness, especially in cases of hydrothorax, when the neglect of
this region has led to the general but erroneous idea that the surface of a pleural
transudation is horizontal.
VII. That an effusion does not immediately intrude between the lung and the
lateral chest wall, but that such intrusions occur last of all, whatever be the posi-
tion of the patient.
VIII. That a pleuritic exudation does not compress the lung in the manner
universally taught, but that, on the contrary, the effusion exerts a negative pres-
sure by virtue of its weight.
IX. That the lower part of the lung does not become first compressed, and
then plunged into the fluid beneath, but that the entire lung contracts symmetri-
cally throughout.
X. That the lung does not, properly speaking, swim upon an effusion, but that,
by virtue of its retractility, it supports the entire body of the effusion, together
with the diaphragm, until the weight of the fluid exceeds the lifting force of the
lung.
XL That the position and shape which the lung assumes when associated with
an effusion are determined by the balance between the weight of the fluid and the
elasticity of the lung.
XII. That the position and shape which the effusion assumes are determined
by the varying degree of retractility in different parts of the lung, and by the
position of the patient, complications, of course, being left out of consideration.
XIII. That the excess of weight of an effusion is free to act upon the dia-
phragm, according to its specific gravity.
XIV. That the diaphragm does not bag down until the weight of the effusion
exceeds the lifting force of the lung, and the same holds good for obliteration of
the intercostal depression.
XV. That the heart, mediastinum, etc., are not pushed out of place by an
effusion, whether of air or of fluid, but that these parts are drawn over by the
opposing lung. Enormous effusions may, of course, increase the displacement.
XVI. That friction sounds in the early stage of pleurisy are not interrupted
by the effusion separating the lateral pleural surfaces, but that they cease because
the respiratory muscles of the affected side are weakened, and unable to cause
sufficient motion for the production of these sounds.
XVII. That the negative pressure of the lung favours absorption into the pleural
cavity.
1878.]
Garland, Pneumono-dynamics.
481
XVIII. That the action of the intercostal muscles favours absorption out of the
pleural cavity (luring inspiration.
XIX. That the negative pressure of the lung favours the diastolic repletion of
the heart, as shown by Marey and others ; and that impairment of the retrac-
tility of the lung must therefore be accompanied by symptoms of imperfect heart
supply, such as cardiac irregularity of action, diminished tension of arteries, and
venous stagnation, as suggested by Dr. T. B. Curtis.
" As I have previously stated, most of the points in this summary I consider
to be original with myself, while others have been merely demonstrated in this
book in an original and, as I think, conclusive manner."
Basing our opinion upon what Dr. Garland has himself conceded, and quoted
in other portions of his book, we cannot but think that he has overestimated the
amount of originality which he has brought to bear upon his subject, since
nine of the above nineteen conclusions are original with other observers, and
to which Dr. G., as far as Ave can see, has added nothing new either in mode
of demonstration or subject-matter. In fact, with the exception of conclusion
XIV., he has not attempted to demonstrate any one of them, resting content with
the mere statement of the observations of others.
On the other hand, before we can accept as final the results embodied in the
remaining conclusions, more notably in VII. and XVI., we must have more proof
of the correctness of the facts and theories here so positively asserted. No one
can deny the value of physiological experiments in the explanation of pathological
facts, but those experiments are only of value in that they accord with those
clinical facts.
Even in the meagre details of the cases reported in the beginning of his book
as typical exemplifications of his theories, we find points which conflict with
those theories, or at least certainly require explanation. For example, in Case
IV. (p. 10), it is stated that there was well-marked oegophony heard over the
region of flatness. The theory usually accepted as explaining this phenomenon
is that the voice is rendered tremulous and vibratory in its passage through a thin
layer of fluid lying between the two layers of the pleura. But according to Dr.
Garland's statements, no such layer exists, hence he should at least have offered
some other explanation.
Then his explanation of the disappearance of the friction-sound in pleurisy, as
due to paralysis of the respiratory muscles from pain, is decidedly inadequate.
That expansion to a considerable extent of the lung on the side affected with
pleurisy does take place, and consequent motion of the pleural surfaces, one upon
the other, is proved in Case III. (p. 9), where it is stated that above the line of
flatness ' ' respiration was heard everywhere accompanied by moist rales on inspi-
ration, and sibilant and sonorous rales on inspiration and expiration ;" and on the
next day, the line of flatness remaining unchanged, "normal respiration was heard
to the base, along the spine, and from one or two inches outwards, the area on
which it was heard increasing towards the upper part." This certainly shows that
there must have been a considerable degree of motion in the affected side, and
yet we have no note of a friction-sound. Then, again, as regards the cessation of
respiration from pain., it is well known that the actual pain of pleurisy is usually
much more acute in the first stage of the disease, when there is merely inflamma-
tory roughening of the pleura with no effusion, and that the occurrence of exuda-
tion is often marked by the entire cessation of pain on respiration. Xor, again,
if we explain the area of flatness as occupied by fluid to the entire exclusion of
lung tissue, would we expect to hear any breath-sounds over this region ; yet in
Case III. it is stated that vesicular and bronchial breathing were heard over a
portion of the region of flatness. We can hardly suppose that a body of fluid
situated entirely below the lung would conduct sounds generated in that lung to
482
Bibliographical Notices.
[April
the chest-wall ; and if Dr. Garland will not allow that there is enough motion on
the affected side to move the pleural surfaces one upon the other, we do not see
how he can consistently explain these breath-sounds heard over the region of flat-
ness as due to the vibration imparted to the walls of the chest bv the expansion of
the lung. This explanation may possibly apply to bronchophony, but, certainly,
in our opinion, not to normal vesicular respiration, which, as quoted above, is
said to have been noticed in one case over the region of flatness.
We must confess that we have closed this book with a feeling of disappoint-
ment. Dr. Garland's conception of the case has been entirely from a physical
point of view. In the excellence and thoroughness of his purely phvsical inves-
tigations, he has been led to overlook the fact that in pleuritic effusions we are
not dealing alone with a simple elastic body, always tending to contract, in a firm,
rigid, unmoving receptacle ; but that in the thorax we have an elastic bod}-,
which, while at one instant contracting through its own elasticity, at the next, in
spite of that elasticity, is expanded by a far greater force ; a body that is situated
in movable walls, walls whose own elasticity has been estimated as more than
double that of the lungs.
In conclusion, we do not wish to be understood as denying the possible truth of
Dr. Garland's conclusions ; we think that they are simply " not proven." AVhat
is needed is a more extended series of experiments in their support, and then their
verification by an extended series of clinical facts. R. M. S.
Art. XXVII. — Ueber Percussion der Knoclcen. Yortrag Gehalten am ersten
Sitzungstage des VI. Congresses der Deutsche)! Gesellschaft fur Chirvrgie zu
Berlin, Am. 4, April, 1877. Yon Dr. A. Lucke, Professor der Chirurgie in
Strasburg. Archiv fur Klin. Chir. xxi. 1877.
On the Percussion of Bones. By Dr. A. Lucke. Professor of Surgery at
Strasburg.
Those who are conversant with the history of medical therapeutics are aware
of the immense influence that is exercised by new and improved methods of inves-
tigation in promoting the development of the healing art. Physical diagnosis, for
example, by discarding the uncertainty of subjective symptoms, has established
safer grounds for medical interference. "Where in former years the physician had
to be content with establishing, often by a very circuitous process, a diagnosis of
greater or lesser probability, the scientist of to-day, drawing on his copious re-
sources, demonstrates with comparative ease and almost absolute certainty the
seat, the nature, and the danger of a malady. This marvellous progress is in great
measure due to the introduction of the laryngoscope, the endoscope, the ophthal-
moscope, the rhinoscope, and similar contrivances, which enable the modern
practitioner to employ exact modes of inquiry. By the agency of such instru-
ments we remove the doubtful character of many diseases, and in so doing improve
our chances of successful treatment. Indeed, if in our times we can ascertain
the incipience of disease where our predecessors failed to perceive any modifica-
tion of normal existence, and if we are thus enabled to avert calamity by a tiniely
remedial interference, we are assuredly nearing the ideal goal of therapeutics, i.e.,
prophylaxis.
The object of this notice is to call attention to the percussion of bones, which
promises to become an important means of facilitating the diagnosis of morbid
changes in their structure. This method, the adaptation of an old principle to
1878.]
Lucke, On the Percussion of Bones.
483
new purposes, originated, and has been practised for some time, at the surgical
clinic at Strasburg, by Dr. A. Llieke. Dr. Lucke states that: —
"The percussion of bones maybe performed, in the first place, to ascertain
their painfullness and extent. It is true, »we have attempted to do this all along
by squeezing, pressing, and tapping the bones with our fingers. But the results
obtained in this way were insufficient and unreliable. I have, therefore, employed
the percussion hammer, and the ordinary ones being found inadequate, I have con-
structed a special bone-hammer, and employ two different kinds of this new
instrument. One rather large and solid, the other somewhat modified and smaller
than the first. Both have an acorn-shaped point made of caoutchouc."
The handle of the hammer is made of whalebone and is very thin, so that it
readily vibrates at the slightest touch. To further facilitate an extensive swing-
ing motion, the head is made of metal, to which is attached a hard-rubber point.
To determine the degree of painfulness in a given case by this method, we must
direct our attention to the possibility of mistaking the normal sensitiveness of an
individual with the corresponding pathological symptom. In order, therefore, to
avoid errors of diagnosis from this source, we should never neglect to practice
comparative percussion of the corresponding bone of the healthy side. The
hammer may be employed very gently, with moderate strength, or very energeti-
cally ; the force of application will, in each case, be determined by the situation
of the bone, and the nature of the disease. Percussion, applied to the bones,
accurately determines the amount of force necessary to produce pain ; and per-
cussion also ascertains the precise quality of any existing painfulness. For
example, when the patient complains of severe aching on gentle percussion, and
the pain becomes intensified as we percuss more forcibly, a superficial affection
may be diagnosed. • When, on the other hand, the pain is felt only on strong-
percussion, the seat of disease is deeper in the bone, or in a neighbouring one con-
tiguous to it.
The diagnostic value of this new method is strikingly illustrated in a case briefly
alluded to by Llieke, which involved the discovery of disease in the astragalus,
and afforded an opportunity of observing the excellent results achieved by the
early removal of degenerated bone. At first direct percussion of the astragalus was
attempted, but, on account of the swelling of the capsular ligaments and synovial
membrane, the results obtained were not sufficiently reliable and characteristic to
justify a definite diagnosis. This plan was accordingly abandoned, and Llieke
undertook the percussion of the posterior projection of the os calcis. When this
was performed in the direction of the long axis of the foot, great pain was at once
complained of, but there was no sensitiveness to percussion in other directions.
Moderate percussion, both of the external and internal malleolus, produced very
little pain, but no sooner was it made at all forcible than the patient experienced
severe aching. Lucke, therefore, diagnosticated central ostitis of the astragalus,
and the subsequent successful operation verified his conclusion.
Bones may, likewise, be percussed to determine differences of resonance de-
pending on their structure. Dr. Piorry mentions this application of percussion.
This author distinguished the specific bone resonance from the dull sound of sur-
rounding tissues, but he mentions the fact as a casual observation rather than an
important discovery. Lucke may, therefore, justly claim the merit of conscien-
tious investigation, and due appreciation of the importance of bone percussion.
He was the first to demonstrate the feasibility of utilizing the results to be ob-
tained by careful attention to comparative percussion of healthy and diseased
bones. He was also the first to show how the normal percussion sound of bones
may become altered by pathological processes ; and he likewise measured the
extent and quality of this modification in the principal osseous affections. He
484
Bibliographical Notices.
[April
finally ascertained that percussion may be employed with two ends in view,
namely, the determination of pain and the observation of resonance, and proves
that the one elucidates and supplements the other.
Experience has shown that " the shaft or diaphysis of long hones gives a
deeper, duller percussion sound than their extremities or epiphyses." Moreover,
the sound emitted by a bone is entirely independent of its connection with a joint
or its contact with surrounding parts ; and Liicke has demonstrated that the cause
of the difference in the sound must be looked for in the essential structure of
bones, and not in any accidental circumstances accompanying the mechanism of
their fixation in the body.
The following kinds of sound have been observed as characteristic of bones :
"high sound, low sound, dull sound, short or high sound, and hollow sound."
We recognize the sound-pitch of the spongy tissue of bones as higher than that
of their compact substance. Here the difference of sound is based on the phy-
sical structure of bone, the compact tissue containing very small cavities with an
abundance of solid matter betAveen them ; whereas the spongy tissue contains
relatively large spaces, and shows a comparative diminution of solid matter.
Percussion of the bones may be advantageously employed to establish, correct,
or verify diagnosis. It will be found serviceable in the early discovery of osseous
diseases, and pre-eminently so where the affection is more or less centrally
located. For the sake of accuracy it becomes indispensable to compare the per-
cussion sound of a suspected bone with that of the corresponding bone of the
normal side. And in thus carrying on a comparative percussion of homologous
parts, care should be taken to avoid errors from accidental resonance. "When-
ever the individual conditions of a given case were such that the extremities
could be freely suspended in the air, Liicke always chose percussion in that posi-
tion. When, for example, the tibia was percussed, the patient's foot was grasped
by an assistant, the limb was lifted from the bed, and held in the air till percus-
sion was completed.
Our present knowledge of bone-sounds may still be said to be in its infancy.
Nevertheless several well-authenticated facts have already been ascertained.
Thus we know that, when congestive hyperaemia or infiltration of the marrow
exist, a certain dulness of percussion-sound is its pathological symptom.
Ostitis, osteomyelitis, and suppurative osseous diseases are likewise charac-
terized by dull sound. This statement holds good both for the shaft and extremi-
ties of long bones, and careful autopsies have confirmed its truth. Wherever
osseous substance is abnormally thick, a similar pathological dulness may be
ascertained. In like manner exostoses, hyperostoses — osseous hypertrophies gene-
rally— give a dull sound.
Consolidated fractures, even those of long standing, sometimes emit a peculiar
dulness, and in such cases an incomplete or misshapen medullary canal is proba-
bly the cause of the symptom. Osseous cicatrices have a duller sound than the
bone substance surrounding them.
All inflammatory processes are marked by a perceptible dulness, and we also
invariably find a decidedly increased sensitiveness. In this way percussion
becomes doubly serviceable, first, by determining the extent and nature of an
affection, and, secondly, by locating with precision its seat in the bone. Of
course, wherever our sense of hearing can be assisted by ocular inspection, visible
changes of form or colour will afford an additional clue to the correct diagnosis.
But the vast importance of percussion depends on the fact that through its instru-
mentality we may reveal disease where the eyesight fails to ascertain it.
We have lately learned to attach great weight to the timely recognition of
1878. J Anderson, Lectures on Clinical Medicine.
485
ostitis, especially in articular extremities of bones. Prof. T. Kocher,1 in Bern,
has demonstrated the possibility of precluding disease of a neighbouring joint by
opening the bone, exposing the seat and nature of the trouble, and effectually
removing or destroying any focus of irritation that may be discovered. Here,
again, to facilitate the detection of degenerated centres, percussion will be found
valuable.
The high percussion-sound and the hollow sound remain to be considered. The
former is found wherever the osseous tissue is very compact and dense, as, for
example, in osteosclerosis. Fungoid growths or granulations encroaching upon
the bone substance of a joint and eroding its cartilages bring about a prominent
change of sound, making it higher and shorter than it would be in the normal
condition of the joint. The hollow sound is most frequently also a high sound,
and occasionally it may even partake of the nature of tympanitic resonance. It
is found accompanying osteoporosis.
It follows from what has been stated that percussion may also materially assist
us in fixing with precision the spot where operation should be performed. Llicke
thinks that percussion will teach us where and when to be very cautious in the
execution of common operations or manipulations, and whether the usual modus
operandi can be safely adhered to or must be essentially modified. As an ex-
ample, he puts forward the forcible extension of articular contractions, an opera-
tion which may unexpectedly result in fracture, if we have failed to recognize an
existing osteoporosis.
From the results already obtained, it may be safely inferred that this method
may become an efficient and valuable aid to diagnosis. E. C. W.
Art. XXVIII. — Lectures on Clinical Medicine; Delivered in the Royal and
Western Infirmaries of Glasgow. By Dr. McCall Anderson, Professor
of Clinical Medicine in the University of Glasgow. With illustrations. 8vo.
pp.268. London: Macmillan & Co., 187 7.
Dr. Anderson has been hitherto principally known in this country as a der-
matologist ; his work on skin diseases being one of the best which has recently
been issued from the English press. It is probable that he still retains a prefer-
ence for this specialty, since he devotes the two concluding lectures in the book under
notice to diseases embraced in this branch of medicine. There are, in all, seventeen
lectures, in which various subjects are discussed, the principal among which may
be said to be aneurism of the thoracic and abdominal aorta, acute phthisis, hys-
teria, spinal irritation, tubercular peritonitis, disease of the pons Varolii, and spinal
irritation. In the first lecture he gives some illustrations of the recent advances and
discoveries in the field of practical medicine, while the second he devotes to the
discussion of pain as a symptom of disease.
In his lectures on aneurism of the arch of the aorta, he gives the histories of
three cases, which were treated by galvano-puncture. In the first case the treat-
ment utterly failed to arrest the course of the disease, which was already far
advanced when it was first instituted. In the second, great improvement was
effected by it, and it is possible that it might have resulted in a perfect cure, if
1 Zur Prophylaxis der fungosen Gelenkentzuendung mit besonderer Beruecksich-
tigung der chronischen Osteomyelitis und ihrer Behandlung mittelst Ignipunctur.
Volkmann's " Sammlung clinischer Vortrage." No. 102. Leipzig, 1876.
486
Bibliographical Notices.
[April
the patient's means had enabled her to lead a life of repose. Instead of this,
hoAvever, she was obliged to earn her living by hard labour, which brought on a
relapse. In the third case, the sac became smaller and harder under its use, and
the pulsation less, showing that some coagulation had taken place. The patient's
condition could, nevertheless, hardly have been considered satisfactory, inasmuch
as he continued to spit blood, and to suffer from dysphagia. These results are
certainly not such as to justify this treatment, until a fair trial has been given to
that of the iodide of potassium in large doses, combined with rest and a restricted
diet.
Dr. Anderson contends that acute phthisis is a disease which may sometimes
end in recovery, and that this result may, in some cases, be brought about by
appropriate treatment. The cases which he reports to sustain this position are
evidently cases of catarrhal pneumonia, involving the apex of the lung, and
accompanied by typhoid symptoms. That catarrhal pneumonia generally pre-
cedes acute, as well as many forms of chronic, phthisis, will, we think, be gener-
ally admitted by the majority of careful observers of disease at the present day;
and that cases occasionally occur, in which recovery takes place, even after the
symptoms have seemed to indicate the existence of serious disease of the lungs,
will, we think, also be cheerfully accorded. We say seemed to indicate, because
a careful physical examination of the chest will generally show that this is not
really the case. In the cases reported by Dr. Anderson, the physical signs are
said to have been dulness at one or both apices, and musical rales heard every-
where over the chest. These are not, it need scarcely be said, the signs which
accompany a breaking down of the lungs. The treatment which was employed
by the author is essentially antipyretic in character, cold water being freely used
as an external application, and a pill resembling that recommended by Niemeyer,
except that it contains a larger amount of digitalis, being administered internally.
Dr. Anderson also contends that tubercular peritonitis is not necessarily a fatal
disease. Recovery having followed the use of iodide of potassium, pancreatic
emulsion, cod-liver oil, and cold-water compresses to the abdomen, in a case
which was under his care. It might be objected, of course, that he had mistaken
the nature of the disease, but he is supported in his opinion by the testimony of
other competent observers, among others by Dr. G. Hilton-Fagge, who says in
the course of a paper on diseases of the liver and peritoneum, in the Guy's Hos-
pital Reports for 1875 (see number of this Journal for January, 187G), that he
has seen several instances in which there was reason to believe that recovery from
it took place ; in one case, indeed, the diagnosis has been afterwards proved to be
correct by a post-mortem examination. But the most remarkable case of recovery
from tubercular peritonitis is that recorded by Mr. Spencer Wells and referred
to by Dr. Fagge in his paper. The patient, a female, ast. 22, was believed to
have an ovarian tumour. She had twice been tapped, eighteen pints having, on
one occasion, been drawn off. It was decided that ovariotomy should be per-
formed, and Mr. Wells made a small incision. But he found that the peritoneum
was studded with myriads of tubercles. He pumped out all the fluid, and closed
the wound. The patient went through a sharp attack of peritonitis, but got well.
Four years afterwards she married. She had no children. But six years later
she was still stout, hearty, and well.
In the lecture in which the author discusses a few of the diseases of the skin,
he calls attention to a form of eruption which he has frequently observed ; but
which, he says, does not seem to have arrested the attention of physicians. He
calls it lupus verrucosus, and thus describes its principal symptoms: —
It always occurs, he says, in strumous subjects, and "commences by the de-
velopment of small, circumscribed, dusky-red, or violet patches, often in the form
1878.] Luxd, Internal Urethrotomy. 487
of tubercles. Sometimes these are isolated, oftener confluent, so as to form
patches of irregular outline and of variable size, as large even, they may be, as
the palm of the hand. I [he] have observed the subsidence of some of these
without undergoing a further development, while others have advanced to suppu-
ration ; but, in the majority of instances, they become covered with wart-like
excrescences, and then these violet-coloured warty patches present an appearance
which, once seen, can never be mistaken or forgotten. The warty formation can
be readily picked oft' without any, or, at all events, without much, pain ; but a
new excrescence gradually grows in the place of that which is removed. The
patches beneath the excrescences are not ulcerated, as might be expected, but
the papilla? are greatly hypertrophied, project in the form of filaments, which
may even exceed a couple of lines in length, and bleed on the removal of the
warty mass. The latter is marked on its under surface by depressions corres-
ponding to the elongated papillae just referred to, and is composed entirely of
epidermis."
The disease does not seem to be of frequent occurrence, for it was met with
only nine times in 5174 cases of skin diseases treated consecutively at the Dis-
pensary for Skin Diseases in Glasgow. Its frequency, as compared with that of
the other varieties of lupus, may be gathered from the fact that during the same
period sixty-seven cases of the latter came under observation. Its prognosis is,
the author says, invariably favourable, although a cicatricial appearance of the
skin is left ; but this is of less consequence than in the other varieties of lupus,
as it rarely, if ever, appears on the face. The treatment comprises the usual anti-
strumous remedies ; cod-liver oil, phosphorus, and iron being especially indi-
cated.
In the same lectures will be found reported an interesting case of ephidrosis
cruenta, or haemidrosis, a disease which the author believes principally occurs in
connection with amenorrhoea, being, in effect, a species of vicarious menstruation.
The discharge became less as the menstrual function was re-established. Dr.
Anderson also gives the details in a case of elephantiasis Arabum, in which great
improvement followed the ligature of the femoral artery. In two cases which
have come under our own observation, the relief from this operation was only
temporary, the disease returning in full force a very short time after the patients
left their beds, and we are therefore inclined to attribute part of the result to the
enforced rest which this treatment necessarily imposes.
The book, as we have shown, contains the reports- of several interesting cases
which have evidently been carefully and intelligently observed ; but the remarks
which these haA*e suggested, although always instructive and appropriate, are
scarcely full enough to justify their author in calling them clinical lectures.
There are several handsome illustrations, and the printing and paper are excel-
lent. J. H. H.
Art. XXIX. — Internal Urethrotomy with its Modern Improvemei-its. By
Edward Lund, F.R.C.S., one of the Surgeons to the Manchester Royal
Infirmary, and Professor of Surgery in the Owens College. 8vo. pp. 33.
London: J. & A. Churchill, 1877.
The author of this essay directs attention to the permanent cure of urethral
stricture by internal incision, and illustrates his subject by the details of a stub-
born case of finely contracted coarctation complicated by perineal fistules, in
which, after patient efforts, a Maisonneuve's conducting bougie finally opened the
way for a flexible gum catheter and a urethrotome, with which division was
488
Bibliographical Notices.
[April
effected from before backwards. After the introduction of moderately large solid
instruments, at increasing intervals, the fistules closed, and a " complete recovery' '
ensued, the urethra admitting "with perfect ease a No. 12 English silver
catheter."
The American surgeon will scarcely regard Mr. Lund as the (Edipus who has
rightly solved the riddle of the permanent cure of stricture. After cutting the
obstruction, he says : " On the third, or sometimes even the fifth, day after the
operation I pass a bougie-a- ventre of the size I have mentioned as corresponding
to a No. 17 English, or, if there is any doubt of its passing readily, one of two
sizes smaller, corresponding to an English No. 15 or 13. This I repeat after a
second interval of five or perhaps six days, then for three times at an interval of
a week, then after an interval of fourteen and subsequently of twenty-eight days ;
it being part of the system that, having once secured a full incision, laceration,
and dilatation of all the resisting fibres of the urethra, there is no fear of such an
amount of contraction as to bring back the urethra to its previous abnormal dimen-
sions."
It will be perceived, from the above extract, that our author overlooks, first,
the very important fact that the calibre, or rather the distensibility, of the urethra,
varies in different persons ; and, secondly, forgets that to bring the strictured
portion up to the size of the normal passage, which is the only rational plan of
treatment, it is essential to ascertain, in each individual case, the natural capacity
of the urethra by previous measurement with the urethrometer. These are cer-
tainly to be ranked among the ' ' modern improvements, ' ' and their neglect is fatal
to good practice. Moreover, in limiting himself to a No. 26 French solid bel-
lied bougie, which he erroneously says corresponds to a No. 17 English, but which
is only slightly longer than a No. 15 English, or in the event of its not passing readily,
to one of two sizes smaller, we are unable to see how he can "secure a full in-
cision, laceration, and dilatation of all the resisting fibres," unless he be operating
upon a urethra the distensibility of which does not exceed the numbers mentioned.
In thus fixing a standard, he wrecks his whole system, since it is obvious that he
will often fail to discover a stricture, much less cure it, if his largest instrument
is less than nine millimetres in diameter. So confident, however, is he of success
that he formulates the axiom which concludes his paper, " Give the operation a
fair trial, and let your strictures cease."
As a means of effecting a permanent cure we cannot indorse Mr. Lund's prac-
tice, but we may congratulate him on having made a slight advance over the
course pursued by those English surgeons who follow the dicta of Sir Henry
Thompson. His remarks upon the employment of filiform bougies in the man-
agement of very narrow or tortuous strictures are most judicious ; and we heartily
commend his advice as to the preliminary and subsequent treatment, the former
being directed to the relief of the concomitant congestion and spasm, and the
latter to averting or mitigating an attack of urethral fever. S. W. G.
Art. XXX. — The Science and Art of Surgery; Being a Treatise on Surgical
Injuries, Diseases, and Operations. By John Eric Erichsen, F.R.S.,
F.R.C. S., Surgeon Extraordinary to Her Majesty the Queen, etc. Revised by
the author, from the seventh and enlarged English edition. 2 vols. 8vo. pp.
947, 989. Philadelphia: Henry C. Lea, 1878.
The position of Erichsen's Surgery was long ago established; will the present
edition serve to maintain it ? Is it fully up to the times ? Are the new things
1878.] Erich sen, The Science and Art of Surgery.
489
noticed, the changes in theory and practice considered, the old errors corrected?
Among the general subjects that have particularly engaged the attention of sur-
geons during the last five years are ancesthetics, antiseptic-surgery, and blood-
less-operating. What says our author respecting them. In the edition of 1873,
ether seemed to be regarded as decidedly a more proper anaesthetic to be used
than chloroform, because of its being "certainly a safer agent." In the present
edition, chloroform is apparently restored to favour, "as being more convenient
and more applicable to certain cases ; though the risk of death being produced is
confessed to be somewhat greater where it is used than where ether is employed,
since ' ' ether less frequently than chloroform produces a direct toxic effect on the
heart." In this acknowledgment lies, we believe, the answer to the question,
"which anaesthetic shall we use?" Ether is the safer, therefore ordinarily
should be employed, without regard to all the disadvantages, real or imaginary,
attending its administration. Attention is very properly called to the danger of
its use in cases in which the actual cautery, therm o-cautery, or galvano-cautery is
likely to be brought "in the neighbourhood of the mouth or air passages." We
have ourselves seen one quite sharp explosion from the ignition of ether vapour,
consequent upon the use of Paquelin's thermo-cautery in a case of removal of the
tongue.
The antiseptic treatment of wounds, and subjects connected therewith, are
treated of much more fully than before. Assuming that "the decomposition of
the fluids of a wound is due to their infection by septic matters .... in the
vast majority of cases from without," Mr. Erichsen asks: " How does the air
infect?" Without pronouncing definitely for or against spontaneous generation,
he accepts the fact of the existence in the air of germs, or, at least, solid particles,
and looks to them "as the true infecting agents, conveyed to and implanted on
the surface of open wounds by the air in which they float suspended in countless
myriads They are organic or inorganic. The organic particles may be
living or dead. But though dead, they may still be capable of infecting an open
wound on which they are deposited."
The practical conclusion drawn is: "Keep out infection, and local destruction
followed by constitutional contamination is averted. Admit it, and every evil,
to those most terrible of all, hospital gangrene, and pyaemia, may occur." Con-
siderable more space than before is given to the description of the "Lister
method," with its essential details, and notice is made of the use of boracic and
salicylic instead of carbolic acid. Of the salicylic acid it is said that " experience
has shown that it is not less irritating ; so that, except in cases in which the smell
is unbearable to the patient, it presents few if any real advantages over carbolic
acid." The conclusion of the whole matter is:—
' ' That the antiseptic treatment has been of much service in the prevention of
the infection of wounds, more especially in old, crowded, and pestilential hospi-
tals, there can be little doubt. We have, however, unfortunately as yet no defi-
nite data by which to judge the comparative merits of this, and other modern
methods of treating wounds. The general recognition by surgeons of the neces-
sity of the free drainage of wounds with or without the employment of antiseptics,
has undoubtedly tended more than any one single improvement in practice to
lessen those evils which necessarily result from the decomposition of pent-up fluids
in contact with raw surfaces. So also the general employment of disinfectants of
all kinds, and the great attention that is now bestowed on hospital hygiene in the
recognition of the importance of abundant air supply and free ventilation, of the
evils of over-crowding, of the necessity of care in the distribution of patients, and
in the avoidance of all carriers of infection, such as sponges, instruments, clothes,
etc., have greatly tended to improve the sanitary condition of most hospitals, and
to lessen the liability to the generation and diffusion of septic disease. The intro-
No. CL April 1878. 32
490
Bibliographical Notices.
[April
duction of the antiseptic treatment being contemporaneous with tlie general adop-
tion of improved hospital hygiene, the patients subjected to this treatment neces-
sarily participate in the advantages that flow from exposure to sanitary conditions
that have been so much altered for the better. Hence it is not reasonable or just
to ascribe a diminution of the amount of septic disease in a hospital in which the
'antiseptic method' is employed to that alone, and to the exclusion of all other
causes. Either hygiene is of no value in surgical cases, or some and probably no
inconsiderable share in the improved results must in justice be assigned to the
generally ameliorated sanitary conditions."
Under the general head of " performance of an operation," " bloodless methods' '
are referred to, bandaging, Lister's method, and Esmarch' 8, the latter being pro-
nounced the most perfect and of "more advantage in operating on diseased bones
and joints, and in the removal of tumours than in amputation." It is stated that
neither the production of sloughing by its use or secondary hemorrhage is "sup-
ported by evidence," and "no case has been recorded in which the products of
inflammation or clots in the veins have been driven on into the circulation by the
application of the elastic bandage." In the chapter on "aneurism" notice is
taken of Reid's successful employment of this bandage in the treatment of popli-
teal aneurism, and it is declared that "this means is applicable to many external
aneurisms, and evidently deserves a further trial."
In the chapter on " Pyaemia" the subject of septicaemia has been treated of much
more fully than before, notice being taken of the results of the numerous experi-
mental investigations made during the last ten years.
Very many changes have been made in the chapter on "Tumours," both as
respects pathology, classification, and arrangement. The sarcomata are all treated
of together, and at considerable length ; an additional group of cancer, the ade-
noid or glandular, is made ; the stroma, the existence of which as properly belong-
ing to the cancer was previously "much disputed," is now declared to be present^
and to "deviate as much as the cells from the normal structure of the affected
part." The three chief views of the origin and growth of the cancer "at present
held by pathologists of high repute" are noticed, and the epithelial theory of
Thiersch and Waldeyer most inclined to, though "the question is necessarily of
great difficulty and presents a large field for further inquiry." The local or con-
stitutional origin is considered at much more length than previously, the conclu-
sion being that : —
"1, cancer is primarily a disease of local origin ; 2, it is often occasioned by
the direct action of local causes ; 3, it is pre-disposed to by various local conditions,
physiological as well as anatomical ; 4, like all other local diseases, it is under the
influence of age, sex, habit of body, and hereditary constitution ; 5, and although
once originating locally, its development is favoured by constitutional conditions ;
6, there is no evidence of the existence of any constitutional state that can pri-
marily, per se, and independently of any local cause, functional or organic, de-
velop a cancer."
The chapters on "Fractures and Dislocations" are much as in the previous edi-
tion. The starch bandage is still given much more prominence than it would seem
to deserve at the present time, since it has been so largely superseded by other forms
of the immovable dressing. The statement is still made that under its use "pa-
tients are frequently cured without any appreciable shortening." Notice has been
taken of subcutaneous osteotomy in cases of badly united fractures, and of Nuss-
baum's transplantation of bone in a case where a portion of the ulna was lost ; but
not of the plan of wiring the bones together in cases of non-union. Nothing is said
of Gordon's over- extension theory of the production of fracture of the lower end
of the radius, although his splint is figured and referred to.
Nekton's line and Bryant's ilio-femoral triangle are described, as also Hamilton's
1 878.] Erich sen, The Science and Art of Surgery.
491
method of treating fractures of the femur in young children, of which method the
author says ' ' I can speak from experience of its use of the very great advantages
of this method."
The ring treatment of fractures is still credited to Eve. Under the head of the
reduction of the dislocated hip by manipulation an interesting account is given of
the first employment of the method by Thos. Anderson, of Leith, in 1775. No
reference is made to Allis's sign of sciatic dislocation, that furnished by the differ-
ence in length when the limb is extended and when flexed on the trunk. (Phila*
Medical Times, March 28, 1874.)
In the chapters on ' ' Aneurism, ' ' the author has for the first time treated of aneur-
ism of the abdominal aorta; has made a more extended notice of the treatment
by flexion and galvano-puncture ; has given Maunoir, of Geneva, and Knight, of
New Haven, credit for first successfully applying, the one flexion, the other digi-
tal compression ; has noticed the treatment by hypodermic injection of ergotin
(" which cannot be considered of a hopeful character" ), and by mechanical means
("as useless as they are unscientific") ; and has enlarged somewhat his statisti-
cal tables. More than eight years ago numerous mistakes in these tables were
noticed in the late Dr. Blackmail's review of the edition of 1869, and yet the
^greater portion cf them still stand uncorrected ; and some of the more recent
ligations of the large trunks have not been tabulated.
The section of the work devoted to the "diseases of the genito-urinary organs"
is introduced by a chapter on the "secondary diseases of the urinary organs
arising from surgical causes," contributed by Marcus Beck; a chapter of much
value, and so written as to render easy of comprehension a subject often not under-
stood by students and practitioners. It is, as heretofore, recommended to use a
gum- elastic tube after lithotomy — as is well known such tube is dispensed with
by the majority of American operators. The advice is now given to carry the
finger along the upper or concave surface of the .staff in operating upon boys.
(Similar advice was given by the former American editor, Dr. Jno. Ashhurst,
Jr., in his work on Surgery.) Notice is taken of Dulles' s statistics of the high
operation — as also of Dolbeau's perineal lithotomy, "the results of which do not
either appear hitherto to have been very brilliant or satisfactory." In treating
of " enlarged prostate" it is still advised to use the metallic catheter, though the
soft catheter is referred to in the paragraph on " retention." We are confident
that by the majority of practitioners, the Nedaton catheter will be preferred, as by
its use the bladder can often be entered with ease after repeated failures with the
silver instruments. The use of the aspirator is not referred to in connection with
" the relief of retention from enlarged prostate when no instrument can be intro-
duced into the bladder in the ordinary way ;" though it is duly noticed in treating
of retention from stricture, and declared to be "upon the whole the simplest
method of treatment and to be preferred to any of the preceding plans, in the
first instance at all events." The views of Otis on the subject of gleet are men-
tioned, as also his urethrometer and dilating urethrotome. Of gonorrheal rheu-
matism it is now and for the first time stated that " it is a disease that appears to
be closely associated with some forms of blood-poisoning, possibly in some cases
with pyaemia." Olive-headed sounds and bougies a boule for exploratory pur-
poses are noticed ; but, as before, metallic instruments are declared ' ' decidedly
preferable in the early stages, and when the stricture is tight, cartilaginous, and of
old standing;" certainly a dangerous statement to make to students, and those
of limited practice in the use of urethral instruments.
But the length that this bibliographical notice has already reached, warns us
that we must hasten to a close. Before doing so we may call attention to a few
other new things that we see have been noticed ; viz., extirpation of the larynx
402
Bibliographical Notices.
[April
(pronounced "at best a barren triumph of surgical skill"); Maunder' s use of
the chisel in subcutaceous osteotomy ; Morrant Baker's vulcanized trachea
tube ; Sayre's plaster jacket ; and the use of the elastic ligature in cases of fistula
in ano. So far as we have had time to examine, there is an entire absence of anv
reference to Maunder' s excision of the lower jaw through the mouth, of excision
for the relief of bunion, of nephrotomy and extirpation of kidney, of subcutane-
ous osteotomy in cases of rickets, and of the treatment of hydrocele by electricity.
The present edition, like its predecessor, is in two volumes, each of which is now
separately indexed ; the illustrations are more numerous and are better engraved.
Though many of the faults of previous editions, that ought long ago to have been
corrected, may still be discovered, yet every one will be satisfied on inspection
that " much new and important matter has been added ;" and the work will
continue to be one of the favourite books of 14 the surgical profession of the United
States," to which the present edition is dedicated. P. S. C.
Art. XXXI. — Vorlesungen ubcr Allgemeine unci Experimentelle Pathologic &
Von Dr. S. Stricker, o.o. Professor der AUgemeinen und Experimentellen
Pathologie in Wien. 1 Abtheilung. Wien: Wilhelm Braumiiller, 1877.
Lectures on General and Experimental Pathology. By Dr. S. Stricker,
Professor of General and Experimental Pathology in Vienna. Part First.
Vienna, 1877.
Every physician is to be regarded as more or less of a pathologist. From
the time of Morgagni, he has been diligently searching for the seats and causes of
disease, less for the sake of knowing them, than for the practical results to be
derived from his knowledge. From the very outset of his career, and in all
times, he is called upon for the explanation of this or that effect — usually some
prominent symptom — and answers with a varying degree of readiness, according
to the predominance of certain factors among the vast number which have brought
him into his present surroundings. As a practical pathologist, his knowledge is
chiefly special, and has largely resulted from clinical experience. He is dealing
essentially with results modified by conditions he may know nothing of, and aris-
ing from causes equally obscure. It is no wonder, therefore, that the history of
medicine has had a varying system of pathology, a science, of disease based upon
the speculations of some prominent clinician, which were transitory as they were
ingenious, and permanent as they were intelligible to the average human mind.
The general pathology of the present day necessarily represents the sum of the
special pathologies of the past, and the desire for generalization finds its expres-
sion, not only in the volume before us, but also in the almost simultaneous pub-
lication of a number of works of the same character. Striking evidence is thus
offered of the accumulation of material, and the necessity for its classification.
In the early part of the present century, the influence of the Paris school was
clearly manifested in the call for accurately observed facts, and the tendency of
the first half of the present century has been almost wholly in this direction.
The facts observed and registered related to disease were pathological, yet their
bearing was special, and not general. During the last thirty years, equal atten-
tion has been paid to accurate observation, but facts have rather been considered
in their relation to others than as isolated events, and the association of cause
and effect has risen to greater prominence.
The progress made in this direction has essentially been due to the luxuriant
1878.] Stricker, General and Experimental Pathology. 493
growth of experimental pathology, a growth so rapid and fruitful as to demand
for itself a high place among the medical sciences. Bedside observation may be
considered a part of the field occupied by experimental pathology, but the methods
of normal physiology have shown a far more productive soil, by. permitting the
utmost possible control of conditions. The pathological physiology of the present
day has already won its recognition as a science, and its results form the most
valued acquisition to the knowledge of disease.
The first part of Strieker's General and Experimental Pathology contains
eleven lectures ; the first three of which are devoted to a consideration of what
disease is, its symptoms and causes, special attention being paid to the effect of
heredity, age, race, sex, etc. A series of five lectures follows, occupying nearly
one-half the volume, and contains an elaborate statement of the history of infection
and contagion. Finally, the phenomena of respiration and circulation are con-
sidered.
Disease is regarded as representing the reaction between external agents and
the organism ; but as health may be represented by the same relation, the addi-
tional element of intensity becomes necessary. All processes taking place outside
the organism may give rise to disease, if their action is sufficient in degree. These
are the external causes of disease, without which the latter cannot exist. There
is, therefore, no spontaneous disease, the use of the term referring merely to our
ignorance of the external causes.
But even with equally intense external agencies, the effect is notably different ;
and, in explanation of this fact, the familiar term disposition is still retained.
All processes within the organism are influenced from without, and, during the
normal course of vital processes, it is impossible for disease to take place, pro-
vided the disposition or temperament is normal. That the latter is abnormal, in
certain cases, becomes a necessary hypothesis, though every effort is made to give
this a material basis.
As all causes of disease are considered as external, these are further divided
into mechanical and chemical. The former are considered as ponderable and im-
ponderable. The ponderable causes are the traumatic — those resulting from the
evident motion of bodies. The imponderable causes result from the action of
forces, whose motion is invisible, as light, heat, electricity, sound, etc.
The chemical causes of disease are likewise twofold in character, those produc-
ing a direct local destruction of tissues, as caustics, and those injuriously affecting
the function of one or more organs, by virtue of their chemical action. The
latter series is composed of poisons, which are inorganic, and organic, living organ-
isms being included among the organic poisons. These organisms may act
mechanically as well as chemically, and are considered as the most probable cause
of the infective diseases. Even were no visible proof of the cause of these dis-
eases to be obtained, it is considered as essential that they must result from the
reception of a material into the body rather than arise from the action of impon-
derable forces. Otherwise the outbreak of the disease must immediately follow
the exposure to the cause instead of taking place at varying intervals afterwards.
In the consideration of the theory of the infective diseases, which forms so large
a part of this volume, attention is directed more particularly to pyaemia, the his-
tory of which serves to illustrate that of the general subject, and it is in this con-
nection that the results of experimental pathology are first prominently presented.
The arrangement of the matter is such that spontaneous generation and inocu-
lation, putrefaction and decomposition, the ground-water theory and soil-emana-
tions, pyaemia and septicaemia, and all the other familiar pterins are grouped to-
gether for purposes of strength or weakness, according as they offer facts of value,
or represent wavering hypotheses.
494
Bibliographical Notices.
[April
The author is evidently in favour of the germ theory of disease, the contaffium
viourriy and offers the following as the principal arguments in favour of this
theory: 1. The morbid appearances — numerous organisms being found in tin-
diseased parts. Although it is not positive that the organisms are the cause of
the disease, still the view is generally favoured that the microscopic organisms
found in certain foci of disease are actually pathogenetic.
2. The results of inoculation ; these compel the conclusion that the agent of
disease is capable of reproduction. The organisms alone in the inoculated mate-
rial are known to have been reproduced.
3. The presence of minute organisms in the kidney of animals, who have
died with symptoms of general disturbance, after the inoculation of material con-
taining organisms resembling those subsequently found.
4. The physical evidence of a suspension of the contagium rather than its solu-
tion, a morphological rather than a soluble agent, and probably of an organized
character.
The general impression derived from reading the first part of Strieker's work
is decidedly in its favour. It seems to be wifely planned, to contain the most im-
portant results of experimental and clinical study, at the same time showing
everywhere an earnest and intelligent criticism, which is manifestly intended to
be wholly free from partiality.
Its tendency is a desirable one, in that it exercises a constant check upon too
devoted an adherence to speculation, while it encourages the formation of a
hypothesis, as suggesting the opportunity for controlling or demolishing the errors
occasioned by less exact statement.
As a series of lectures, it represents the sort of training in general pathology
offered in Vienna at the present day. Although (.-ailing attention to the numer-
ous gaps in exact knowledge, it endeavours to fill them, yet does so by exposing
the weakness of the material, which is interpolated. Each reader is furnished
with the data which permit him to classify his ideas, and, at the same time, has
his attention called to the existence of problems, the subsequent proving of which
may require important modifications of his classification. II . H. F.
Art. XXXII. — Illustrations of Clinical Surgery. By Jonathan Hutchin-
son, F.R.C.S. Folio, pp. 173-191. Philadelphia: Lindsay & Blakiston,
1877.
It is probably owing to exigencies connected with the preparation of stones,
and the consequent difficulty of publishing each fasciculus at the most desirable
time, that the subjects of Mr. Hutchinson's portraits are not grouped in the man-
ner best adapted for study. Some time since we had two fasciculi dealing with
injuries of the head, which possessed great interest, and now we have another
upon the same subject ; but meantime two other numbers have been interjected,
which discussed widely different themes.
Plate XXVIII. comprises three fig-ures, of which number one furnishes an
illustration of " scratch fracture," in which, despite the apparently trivial char-
acter of the bone injury, death from pyaemia resulted on the fourteenth day.
Such a result hospital surgeons, familiar Avith the insidious advance of disease in
the diploe, will not be surprised at. This illustration is furnished by the same
case, which in a former part afforded a picture of inflamed dura mater with a
thrombus in the longitudinal sinus, and when this picture is studied in connection
18/8.] Hutchinson, Illustrations of Clinical Surgery. 495
with that, we have a valuable history of such cases. Figure 2 shows a vertical
fracture so extensive, and the anterior third of the calvarium was so nearly com-
pletely separated from the remainder that some crepitus could be developed. The
cerebral injuries in this case were extensive, and death resulted in four days.
Figure 3 depicts the result of a bullet- wound produced post-mortem. Owing to
the fact that much greater resistance to the effects of violence is shown by the
human skull after death, such experiments, once so common, possess little or no
value, while unhappily the perpetual waging of war in one part or another of
Christendom, affords so many specimens of injuries inflicted by bullets upon the
living skull, that we confess to some surprise that Mr. Hutchinson should depend
upon the results of a more than doubtful experiment to establish his point.
Figures 1 and 2, in Plate XXIX., represent the post-mortem appearances m a
ease where extensive fissures of the base of the cranium and contusion of various
parts of the brain substance coexisted with an undetected depressed fracture of
the vault. Death followed in four days, arachnitis having been developed.
Although the brain injuries were probably too severe to admit of recovery, even
had elevation of the depressed bone been accomplished, yet Mr. Hutchinson
thinks, had the attempt been successfully made, the prospects of the patient
would have been much better. In support of this opinion, he narrates a case
which quite recently came under his hands, where the symptoms were as nearly
as possible identical, in which he removed some fragments, and elevated the rest
with a successful issue. Figure 3 represents a fissure of the orbit of ordinary
type. Figure 4 is taken from a case of fracture of the base of the skull pro-
duced by the forcing upwards of the condyle of the lower jaw. The subject of
this accident was a boy whose head was run over by a cab, and the force of the
collision was so applied that the condyle of the lower jaw punched out a piece of
the skull lying immediately over it, the size of a finger-nail. The necropsy did
not extend beyond the head, and death, which ensued upon the fourth day, may
possibly have resulted from trunkal injuries, as those sustained by the cranial
contents appeared quite trivial.
Plate XXX. is occupied with three illustrations of fractures, which were prin-
cipally noticeable from their extent.
The three figures which are included in Plate XXXI. are of great interest.
One of them shows a post-mortem result, while the other two are portraits of
the conditions which were supposed to exist, but which could not be verified, on
account of the recovery of the patients. In all three cases the trephine was used,
and it is this fact which at once arrests the attention of the practical surgeon. The
extreme and well-nigh heroic practice of Percival Pott and John Bell, great sur-
geons though they were, has been followed by the adoption on the part of many
surgeons of an opposite line of practice equally extreme. By some authorities,
now exercising a wide influence, we are cautioned against any interference with
depressed bone by means of the trephine, or, at least, its use in such cases, if not
interdicted, is looked upon with very grave suspicion. So far has this doctrine
been held of late years, that we have known an excellent surgeon to decline the
use of the trephine in a case of punctured fracture, and allow the patient to die
with the spiculae, which invariably attend such cases, still projecting into the sub-
stance of the brain, the direct exciting cause of the fatal abscess. We are told
that we may venture to elevate portions of depressed bone if we can get the
point of an elevator to take hold, or we may even go so far as to remove an ob-
structing piece of bone with Hey's saw; but there we must hold our hands.
The writer of this notice has always held an opposite opinion. While compound
depressed fractures of the skull are always very serious injuries, and will ever be
apt to be followed by fatal consequences in a large percentage of cases, whether
496
Bibliographical Notices.
[April
trephining is resorted to or not, we have never been able to divest ourselves of
the opinion that this operation, like many others, finds its principal danger in
delay, that like herniotomy and tracheotomy, it is not so often the operation that
kills, as the diseased condition which is allowed to go on unrelieved. When, as
the result of trephining and elevation of bone, a cerebral abscess is discharged,
there may be a very strong feeling in the mind of the operator that the condition
of the patient is desperate ; but at the same time it is difficult to resist the opinion
that, had the same operative measures been resorted to earlier, his prospects would
have been much better. The plates in this number are uncoloured, and there-
fore less striking to the eye, but the instruction to be derived from them is not
less than in the case of the other fasciculi. S. A.
Art. XXXIII. — Landmarks, Medical and. Surgical. By Luther Holden,
F.R.C.S., Vice-President and Member of the Court of Examiners of the Royal
College of Surgeons of England ; Surgeon to St. Bartholomew's and the Found-
ling Hospital. From the Second English edition. 12 mo. pp. 128. Phila-
delphia: Henry C. Lea, 1878.
The little book before us, dedicated to the "students past and present of St.
Bartholomew's Hospital," is an American reprint of a republication, with addi-
tions, of a paper which originally appeared in St. Bartholomew' s Hosjrital lle-
ports. It is precisely what its name imports, a gathering together and digest, as
it were, of those anatomical landmarks, which are of such value as guides, not only
to the practical surgeon, but also to the physician in his daily work. By the term
"landmarks," the author means the "lines, eminences, and depressions which are
guides to an indication of deep-seated parts."
It is not our purpose here to follow closely the anatomical details which are so
ably presented by Mr. Holden. We can only refer our readers to the book itself.
It is essentially a work of reference, in which the busy practitioner can find at a
glance, the data so often desired at a moment's notice, and which cannot always
be found in the treatises on anatomy without considerable research.
The arrangement of the Landmarks is according to regions. The first con-
sidered are those of the head and face, including the mouth, nose, throat, and
features. The neck is then taken up, and this chapter will be found of great
value, bearing, as it does, upon the operations of tracheotomy and the ligatures of
the great vessels, and on the precise position of the apex of the lung.
The study of the chest region comes next, and rules for counting the ribs and
for finding the outline of the heart and lungs are given. In the chapter on the
back we are presented with a tabular plan of the parts opposite the spines of the
vertebras, and rules are laid down for fixing the origin of the spinal nerves.
In the pages devoted to the abdomen, the abdominal lines, the umbilicus, the
parts behind the linea alba, the peritoneum, the significance of the various bony
prominences, the abdominal rings, and the precise location and detection of the
viscera are fully considered. To the general practitioner this matter will be found
of the greatest interest.
Mr. Holden on the succeeding pages examines the landmarks of the perineum
and rectum, and sums up the external anatomy of the lower extremity, in-
cluding the buttocks ; and of the upper extremity, including the shoulder and
axilla. The final pages of the book are devoted to the subject of palpation by
the rectum and of examination per vaginam.
1878.]
Transactions of State Medical Societies.
497
From this sketch of the contents of the book it will be seen that the object of
the author has been to present, in condensed form, those external landmarks, a
knowledge of which is so often desired especially when the memory is a little at fault.
We think he has most happily succeeded in his design, and that he has in this
unpretending little volume furnished, not* only students of anatomy, but the pro-
fession in general, with a manual of ready reference, which may prove of far more
value than many a treatise of greater pretensions. Its pages are full of practical
medical and surgical hints, and we are quite sure that Mr. Holden's solid reputa-
tion as a skilful anatomist and learned writer will be still more enhanced by its
publication. J. H. B.
Art. XXXIV. — Transactions of State Medical Societies.
1. Transactions of the Texas State Medical Association, April, 1877, pp. 242.
Marshall, Texas, 187 7.
2. Transactions of the Medical Association of the State of Alabama, April,
1877, pp. 190. Montgomery, Ala., 1877.
3. .Transactions of the Medical Society of New Jersey, May, 1877, pp. 270.
Newark, 1ST. J., 1877.
4. Transactions of the Medical Association of Georgia, April, 1877, pp. 198.
Atlanta, Ga., 1877.
5. Transactions of the Minnesota State Medical Society, June, 1877, pp. 180.
St. Paul, Minn., 1877.
6. Transactions of the Kentucky State Medical Society, April, 1877, pp. 216.
Louisville, Ky., 187 7.
7. Transactions of the Neiv Hampshire Medical Society, June, 1877, pp. 119.
Concord, X. H., 1877.
8. Transactions of the Medical Society of North, Carolina, May, 1877, pp. 88.
Salem, X. C, 1877.
9. Transactions of the Medical Society of the State of Pennsylvania, June,
1877, 8vo., pp. 310. Philadelphia, 1877.
10. Transactions of the Indiana State Medical Society, May, 1877, pp. 169.
Indianapolis, Ind., 1877.
11. Transactions of the Kansas Medical Society, May, 1877, pp. 79. Law-
rence, Kansas, 1877.
1. In the Transactions of the Texas Society we find an interesting paper by
Dr. Carothers on the causation of Calculous Disease. He attributes the for-
mation of vesical calculus to local rather than diathetic causes. A catarrhal in-
flammation of the lining membrane of the pelvis of a kidney, if of a somewhat low
and chronic type, gives rise to secretion of a viscid mucus. In the presence of
this substance the uric acid, normally in solution, crystallizes, forming with the
mucus a semi-solid mass. Once begun, growth is easily understood. When
driven from the kidney into the bladder, the nucleus acts like any other foreign
body. The difference of the vesical mucus from that of the pelvis is believed to
be the cause of the phosphates supplying, in whole or in part, the place of uric
acid in its later growth. That the stone may originate in the bladder, by pro-
cesses similar to those described as occurring in the kidney, is not very distinctly
stated, though apparently implied. The arguments against diathetic and dietetic
causes, here brought, are strong as to the beginning of calculi, but not equally
so, it seems to us, as to their subsequent growth.
From an instructive report upon Ophthalmology, by Dr. Manning, we learn
498
Bibliographical Notices.
[April
that conjunctivitis is extremely common, and blepharitis marginalia not rare, in
Texas. The "lime dust" from the prairies, and the high winds, often of rapid lv
changing temperature, are named as the probable causes.
In a paper upon Myocarditis, Dr. Goldmaxx makes some interesting sug-
gestions. Absence of the first sound, for a few beats, its reappearance in a
muffled tone, again to disappear, together with an almost imperceptible pulse,
are the physical signs thought to be especially characteristic. That attenuation
of the cardiac walls sometimes attains to such an almost incredible degree without
rupture, or previous to it, the writer believes to be due to the elastic pressure and
support afforded by the lungs.
2. To the Alabama Transactions Dr. Jerome Cochraxe contributed a paper
on the Causation of Yellow Fever. He believes in a specific poison conveyed by
organic germs, which last are capable of development within the human body,
and possibly without it, under certain conditions.
A curious case of - Injury by the Electric Strok e is here reported. Although
the fluid first touched over the spine of the scapula, causing superficial sloughs, it
was not till it reached the lower part of the leg that very serious harm was done.
Here the sloughing was so extensive and so deep that the loss of the leg was an-
ticipated. On separation of the sloughs, the lower part of the fibula seemed to
have lost its vitality. By the fortieth day the inflammation and suppuration had
extended to the knee, or higher, and amputation was done at the middle third of
the thigh.
3. In the New Jersey Transactions we find a contribution to our knowledge of
that affection often knoAvn as Hay Fever or Autumnal Catarrh. Its author, Dr.
Marsh, is himself a victim of the disease. The pollen of certain plants, espe-
cially that of the " ragweed," he believes to be undoubtedly the exciting cause.
Experiments of his own confirm those made by Blackley and Wyman as to
the general diffusion of pollens, especially of the ragweed, at the time the disease
prevails, and also as to the effect produced on susceptible subjects when a few
grains are placed within the air-passages.
Fatal obstruction of the bowels, in an elderly man, was found after death to be
due to the presence of an olive-shaped concretion, seven inches above the ileo-
cecal valve. On careful examination, no nucleus, and no definite structure,
could be detected. Vegetable fibre alone could be identified.
A fatal case of greatly enlarged spleen, in a lad of thirteen, is very imperfectly
reported. A most extraordinary feature in the case seems to have been the
enormous amount of blood thrown off by the stomach, at periods, weeks or
months apart. On one of these occasions, three attacks of vomiting occurred
within six hours, to the estimated extent of three quarts in all. Yet he would
soon rally from such seizures, and resume attendance at school. Just before the
fatal attack, he had seemed decidedly improving, with diminution of the tumour,
under the use of ergot injected over the spleen.
A case of sanguineous cyst, originating in the sacrum and ultimately filling the
whole pelvis, is described by Dr. W. Piersoxt, Jr. Great interference with the
functions of the rectum and bladder, frightful suffering, and possibly the large
amount of chloroform used, caused death four years after the accident which began
the trouble. The patient, a heavy man, had sat down violently on the floor.
When we read a report by Dr. Southard, upon the Water-supply o f Newark,
we can only wonder that its mortality is not higher than 30 per thousand.
More than half its people drink well-water. There are estimated to be 15, 000
cesspools and privies. As a rule, one of these and a well occupy each back-
1878.]
Transactions of State Medical Societies.
499
yard, in the sections unsupplied with aqueduct water. Analysis "fully confirms
the fears excited by this proximity, and by the character of the soil and surface.
As if the cesspool filtration was not bad enough, the laying of sewers (with dry
joints) in many streets was found to lower the water in adjacent wells; and of
course when the latter are low the curi'ent is liable to be reversed. A public
pump, at a street corner, yields water dangerous!}' loaded with sewag-e. And
people who have aqueduct water in the house, send for this pump-poison because
they like it better. The former is by no means pure, but relatively far better.
Menstruation, beginning at fourteen, and still continuing regularly at seventy-
three years, is reported by Dr. James Craig. Health was always good, and the
function continued during three pregnancies and periods of lactation. And on
the other extreme, he describes a case in which, from a mother's report, the cata-
menia appeared at four years of age, continuing till ten, and then ceasing till
fourteen, when they became, and continued, regular.
Dr. Ryerson reports an instance of a child, four years and seven months old,
who lived four weeks with over an inch of No. 1 sewing needle in the heart. At the
autopsy, it was found to have passed partially through the cartilage of the fourth
rib, into the wall of the right ventricle. Pus welled up through the perforated
cartilage, and loose, in an abscess holding one or more ounces of pus, in the mus-
cular substance, lay the needle. It was supposed that, until loosened by suppura-
tion, the broken end remained fixed in the rib, thus pinning- the heart to the chest-
wall. An attempt during life to discover and remove the needle had failed.
A ci/stic tumour, the size of a small egg, and occupying the cavity of the right
ventricle of the heart, is reported by Dr. James. The sac was broken, appa-
rently before death. What appeared to be pus, with dark, clotted blood, oozed
from it. Heart, much enlarged, was filled with coagulated and dark-coloured blood,
as also were the aorta and other great vessels. The lungs were "almost hepa-
tized," and contained small particles of purulent matter, apparently derived from
the cyst.
4. In the Transactions of the Georgia Society the formal addresses are unusu-
ally good.
Dr. A. W. Calhoun reports the successful treatment of symblepharon by
dividing the adhesions with a scalpel, and fixing by sutures a portion of a rabbit's
conjunctiva iu the position held by the normal membrane in health. Only one
adhesion, near the inner canthus. marred the success. The rabbit's eye, strangely
enough, healed without any adhesion of the raw surfaces of lid and ball.
The use of chloroform as an anaesthetic in surgical cases seems to be quite
general in Georgia. We notice in one instance of its use, the patient was held up
by the heels three times, in consequence of as many stoppages of the heart.
To assist the evacuation of matter from carbuncles, Dr. Leitner recommends
the use of cups, applied over and surrounding the diseased spot, just as they would
be over a scarified surface to promote bleeding. For felons or small boils, the
same principle may be applied by using the barrel of a glass syringe, to be ex-
hausted by suction from the lungs. He has found these methods of very great
use in relieving pain, and hastening a cure.
Dr. Hunter believes that fib rou s tumours of the uterus are much diminished,
if not cured, by muriate of ammonia. Two cases are given,
5. In the Minnesota Transactions we find an attempt, by Dr. J. C. Bosser,
to trace the effect of meteorological causes upon the attacks, or exacerbations and
remissions, of neuralgia. We do not find the diagrams here given at all clear.
If we understand the text aright, intercostal neuralgia got worse with a rising
500
Bibliographical Notices.
[April
barometer. " Cervieo-brachial and sciatic neuralgia follow high ranges of hu-
midity and high barometric pressure, developing immediately after and in the rear
of storms." Neuralgia of the trigeminus, he says, differs from the above forms,
" and seemingly relates more closely" to rising temperature and moisture, with
low pressure. The connection between facial neuralgia and malarial poison is, he
thinks, supported by these facts.
Dr. J. H. Murphy removed a vesical calculus, nearly two inches long by <ix
lines in thickness, which had for nucleus a minie rifle-ball, received into the bladder
eight years before, while serving in the Avar of the rebellion.
Dr. L. P. Dodge reports a case of double uterus and vagina, in a woman of
twenty-five years. The left vagina was the larger. Septum complete. Two
cervices, each with its os, were well developed. There were two uterine cavities,
with septum as in vagina. Menstruation was from both divisions, and was habitu-
ally painful and irregular. Patient was childless after six years' marriage, and
sought advice on account of painful and difficult coition.
We find here a curious case of arrested fcetal development. A tumour, weighing
six pounds, and supposed to be one of the ordinary fatty variety, removed from
the lower border of the thorax of a healthy, middle-aged woman, was found to
contain a central cavity, with lining membrane, and some remains of a foetal
skeleton. The tumour was reported to have been congenital ; to have begun to
increase in size twentv years ago : and to have been for "some time" discharging
pus and portions of bone through an ulcerated opening.
6. In the present issue of the Kentucky Society, Dr. W. T. Owen combats the
views of Dr. Ely McClellan concerning cholera. He believes the presence of
malaria to be necessary to the appearance of cholera. It is not that malaria, or
the conjunction of vegetable decay, moisture, and heat, is the sole cause, but only
the condition without which the disease never occurs. The writer, also, warmly
disputes the portability of cholera.
Here, as in several other of these publications, we find testimony to the ex-
ceeding virtue of salicylic acid in acute rheumatism. Dr. YandeU, Jr., gives
ten to thirty grain doses, rubbed to a paste with a teaspoonful of cream, and then
stirred into four ounces of milk or cream.
In an article on occipito-posterior positions, Dr. Logan contradicts the some-
what prevalent impression that negro women get through child-birth and its results
more easily than whites. He has not found, either, any marked difference in the
shape of the foetal head in the two races.
Dr. D. S. Reynolds advocates iridectomy as an almost certain cure for irido-
cyclitis, appearing as a syphilitic symptom. Proper constitutional treatment is, of
course, also necessary.
7. To the reader of the New Hampshire Transactions, the chief attraction
will be found in two admirable addresses, respectively by Dr. A. B. Crosby and
Dr. A. H. Crosby. Both are overflowing with wit and wisdom, but are utterly
insusceptible of analysis. The subjects are, The Ethical Relations of Physician
and Patient; and Orthodoxy and Heterodoxy in Medicine.
Dr. S. J. Allen describes what he claims as a new, easy, and unfailing method
of reducing luxations of the hip-joint. Standing astride the patient, he lifts the
affected limb, placing his hand in the popliteal space and bringing the foot between
his legs and against his perineum. The thigh being thus flexed at right angles to
the body, and the knee also bent, the surgeon lifts vigourously till he raises the
hips off the bed. This, of course, turns the patient from his back over upon one
side ; and after holding him thus suspended for a few seconds, the head slips back
1878.]
Transactions of State Medical Societies.
501
into the acetabulum. The patient is supposed to be fully under the influence of
anaesthetics. The four illustrative cases are all of dislocation upon the dorsum ;
but the writer claims that the other and rarer displacements all pass into the former
before reduction is accomplished.
Dr. J. W. Parsons reports the death, apparently from intercurrent acute
tuberculosis, of the patient whose extraordinary tolerance of empyema, pneumo-
thorax, and aspiration, were described in the Transactions for 1876. From
March 17, 1876, to March 24, 1877, aspiration was done ninety-three times. At
the end of that time, a curved canula was inserted between the eighth and ninth
ribs and kept there. During the summer and fall he did what he called light
work, and said he " often did a man's work " — and the lightest labour of a New
Hampshire farmer is no trifle. He was loading his wagon with sea- weed, at the
shore, when he caught the cold in November, which seemed to lead to his death.
This finally occurred from pulmonary hemorrhage, May 26. The left pleural sac
had a capacity of fully two pints, with walls thickened and rough. The lung?
compressed against the spine, about six inches by four, and one inch thick, was
firmly bound down, presented no trace of air-cells, but showed points of communi-
cation between the bronchi and the sac. The right lung had its interior thoroughly
honey-combed with cavities, and what lung-tissue remained was sown with tubercle
in all stages. This disease was believed to be of recent origin. That upon the
left side dated about five years back.
8. To some of our readers, sensitive to the reproach brought upon our city and
profession by bogus "colleges," it maybe some consolation to learn from the
North Carolina pamphlet that a duly incorporated medical college there exists,
having but one " professor" or teacher, assisted by his son as "demonstrator,"
who has never seen another college. This admirable institution has for ten years
turned out annual graduates^ armed with the all-suflicient parchments.
Dr. Wood regards it very important in the treatment of tapeworm that the
parasite, when passing from the body, be received in warm water, Otherwise
the extruded portion loses vitality, and is more apt to break and leave the head
inside, whereas, if kept alive and whole, the weig-ht of the part expelled soon
brings down the rest.
Dr. Gkissom contributes an excellent paper on epilepsy. Many facts and re-
lations, but little known to many physicians, are here clearly brought out.
Dr. Lane describes a case of extroversion of the bladder, with non-union of
the pubes, and non-development of the genital organs, in a little girl two years
old.
In a paper on hypodermic medication. Dr. Foote expresses a belief that am-
monia thus given may prove curative in hydrophobia. He loosely states that a
medical friend bitten by a rabid dog, whose bite gave fatal rabies to four goats
and one hog, and who himself " suffered from the constitutional effects of the
poison to an alarming extent," recovered under thirty-drop doses of strong am-
monia frequently repeated.
9. The solid volume of the Pennsylvania Transactions necessarily contains
much interesting matter at which we cannot even glance.
Dr. Lenox Hodge's Address in Surgery contains two very instructive cases of
reflex epilepsy, both cured by the removal of cicatrices. In each instance the
wound was about the head. Excisions of the spleen, kidney, lower end of rec-
tum ; subcutaneous osteotomy; and abdominal section for the relief of "intussus-
ception, for removal of foreign bodies from the stomach, and for extra-uterine
pregnancy, are among the topics noted as indicating recent advances. The so-
called antiseptic method as applied to wounds and operations is highly estimated.
502
Bibliographical Notices.
[April
Dr. Ccrwen's Address in Mental Disorders is very well adapted to convey to
the general practitioner a knowledge of insanity, which would seem to be much
needed
The invariable diagnostic importance always to be attached to a persistent mus-
cular contraction, is the chief lesson drawn by Dr. Bcnj. Lee from a case of j^soas
abscess. Such contraction, however slight in degree, should never be lightly
valued. It points generally to grave disease in joints, nerve trunks or centres,
or in parts so close to these last as to cause irritation if not organic lesion.
Dr. Allis directs attention to a fracture of the ulna in its upper third, accompa-
nied by forward dislocation of the head of the radius. He explains, by the aid
of simple diagrams, that, in the position of the limb and with the direction of vio-
lence by the conjunction of which only this particular fracture would seem likely
to occur, the displacement forward of the radius would naturally follow. Flexion
of forearm upon arm at right angles, with the breaking force acting at or near
the site of fracture, and in the direction parallel to the humerus (and at right
angles with forearm), are the conditions here assumed as determining the special
traits of this injury. The shock that breaks the ulna forces the head of the
radius from its articulation forward, and, as to the humerus, upward. In cases
where the dislocation has not been remedied, no very serious limitation of motion
results, beyond inability to flex the joint much beyond the right angle.
Dr. W. R. Hamilton, of Pittsburgh, describes a modification of Syme's am-
putation, whereby greater ease and rapidity are attained, with freedom of the
heel-Hap from straining, bruising, or laceration. His improvement seems to con-
sist in deferring the troublesome dissection of the flap until he has made the
dorsal incision and opened the joint. He can thus perform the separation of in-
tegument from the os calcis, from the front and from above, downward and back-
ward, if we understand rightly. In addition to the advantages just mentioned,
it is claimed that the dissection can be carried closer to the bone, even taking off
some fibres of periosteum, and wholly avoiding injurious hemorrhage. Less
danger of sloughing is claimed also ; and it is said that the plantar incision can be
made further forward than in the old procedure.
Dr. John H. Packard reports excellent results from the use of elastic ligatures
in laying open, and thereby curing, urethral fistula1. Perineal section being done
upon a staff, the ligature was passed through each fistula and through the wound.
A moderate tension, renewed every two or three days, brought the ligatures rap-
idly and pleasantly to the surface, union closely following up the ligatures, as
they passed through the tissues.
Passing to reports of county societies, we notice in the mortality returns of
Allegheny County a great diminution in the deaths from " cerebro-spinal fever."
For four successive years, 1873 to 1876, the figures are 103, 18, 20, and 2. Xo
comment is made upon the change.
The prevalence of smallpox in Reading, coming so soon after the terrible les-
sons of 1871-2, is not only sad, but absolutely disgraceful to the community that
could permit it. Of cases there were 848, and of deaths 186, in eleven months,
beginning June 1, 1876. Over five hundred of the sick reported that they had
never been vaccinated, or that the operation had failed. Other zymotic diseases
furnish a pretty large mortality. Neglect of vaccination ; crowded population in
filthy, low, and ill-drained streets ; cesspools, shallow and untended ; and possi-
bly the underlying stratum of clay in the worst neighbourhoods, are noted as the
principal apparent unwholesome circumstances.
In Delaware County a man came home, sick with typhoid. Five members of
his family were successively attacked, although the neighbourhood had been and
continued free from the disease. The house was wretched in respect to light and
1878.]
Transactions of State Medical Societies.
503
air. Another outbreak of this fever occurred ill a space of some two miles in
length along the Darby Creek. Thirty cases in some twenty families were noted,
and " every one of these persons had used milk from the farm to which the first
case had been brought." The Interwords quoted lead us to infer a connection
between the Jive cases and the thirty eases ; but the report is not definite, and no
date is given for the first group. The account goes on to state that " the clothing
of this family" [where the five cases happened?] "had been washed at the
spring-house where the milk was kept, and probably the same boiler used that
was used in washing milk-pans and cans. The sale of milk was stopped, and in
two weeks new cases ceased."
Severe epidemics, or endemics, of diphtheria are noted by several reporters.
From Lehigh County, especially irom Ailentown, we hear of an outbreak, simul-
taneously in different parts of this city, after a period of unusual healthfulness.
The cases were very severe, and the contagion very marked. The attack was
very sudden, with high fever, temperature four or five degrees above the normal
standard, vivid redness of pharyngeal surfaces, with swelling speedily followed by
exudations. The majority of deaths were due to blood-poisoning; others to exu-
dation. The membrane often extended to the posterior nares, Eustachian tube,
and the middle ear. Muscular paralysis, after recovery from exudative processes,
developed gradually from the muscles of the affected locality to the neck and the
extremities. Irregular and intermittent heart action was not infrequent. Epis-
taxis, fatal sometimes, was quite common, but no statistics of cases are given.
Of some 360 deaths from all causes, 64 are attributed to diphtheria.
An extremely interesting paper on the meteorology and epidemics of 1876
forms a portion of the Philadelphia County Report. The heat of July is spoken
of as wholly unprecedented for degree and for continuity. Europe suffered
almost as much as America. An extraordinary development of parasitic insects,
fleas, and other domestic pests, weevils and worms, etc., was noticed as an attend-
ing circumstance. A complete absence of solar spots was remarked, between
March 25 and June 22. In Philadelphia, the death-rate, based upon careful
estimates of population, was slightly less for the whole year than the average.
For the month of May, it was somewhat above ; which the committee incline to
attribute to the crowding, excitement, and over-exertion attendant on the opening
of the exhibition. In June the rate fell off considerably, in spite of two hundred
deaths from cholera infantum. The terrible and never-to-be-forgotten July, wit-
nessed 600 deaths from the cause just named, and 127 from sun-stroke. If these
be deducted from the total, the mortality will be less than obtained in March, with
its 800 victims to pulmonary complaints. The total mortality of 18,892 was 1087
greater than in 1875. Of this excess more than half was among infants and the
very aged; and phthisis killed 317 more persons than in 1875. The remaining
excess is so slight as scarcely to need accounting for by the increase of population,
and by the exhibition.
Among the fluctuations of mortality from special causes, the increase of typhoid
attracts attention. The 761 deaths exceeded those of any year since 1865. The
number in 1875, too, had been unusually low, 419. This excess of typhoid, the
committee are disposed to attribute to the joint action of drought and extreme
heat. Impurities in the water are thus less diluted, and surfaces usually covered
with water are left exposed to the sun. A very much greater increase of typhoid
mortality is thus explained for the city of Paris, in the same year, by Dr. Bour-
don, of "La Charite." The unusual number of steamers, stirring uj) the shallow
waters of the Schuylkill, is also mentioned as a probable factor in our own case.
The "centennial sickness," so called, is believed by the committee to have been
not one definite malady, but many forms of disturbance. Diarrhoea, debility,
504
Bibliographical Notices.
[April
typhoid, and typho-malarial are here named. In addition to the many and ob-
vious causes of disease attendant on the occupation and mode of life of our visitors,
crowd-poisoning is suggested as an extremely probable producer of disease. To
one who has pressed through the sweltering masses in the Memorial Hall on
a special "day," this hypothesis presents no difficulties. Imperfect drainage of
the immediate site is also adverted to. We remember noticing that the floor of
Machinery Hall was laid directly upon a wet, quaking, and elastic clay.
The fact, apparently wholly ignored by some alarmists and critics, that a cer-
tain proportion of our visitors were absolutely sure to die within a certain time,
is well. brought out. Allowing only for a death-rate less than obtains among the
New York police — picked men in the prime of life — it is carefully estimated that
up to Dec. 11, 6000 deaths should naturally occur among the returned visitors to
the exhibition, independently of special causes therewith connected.
A smallpox mortality for this city, of 407, while not so outrageous as that of
Heading, is yet all wrong, and should excite the earnest attention of the Board of
Health.
In the Schuylkill County Report, we find a notice of a boy of fourteen becoming
impaled upon the end of a carriage thill or shaft. Boy and vehicle were moving
rapidly in opposite directions. The smooth worn point of the shaft entered one
inch below the left nipple, and came out behind, the precise point not being
stated. Swung three times into the air by the rearing of the horse, he then
pushed himself off the shaft, and walked home with some assistance. No cough
nor hemoptysis followed, and apparently little shock. Effusion into the pleura
occurred, with free discharge of pus from both wounds. This gradually lessened,
and finally both wounds closed, the anterior last, and the boy was in robust health.
Dates are not given, nor are many details which we should like to know.
Dr. John T. Carpenter treated an elbow, which was completely shattered by a
heavy load of shot from a gun in the patient's own hands. A more complete
destruction of the parts could hardly be imagined, except that the arteries escaped.
The lower two inches of the shaft of the humerus, with its condyles, were sawed
off, and the head and upper end of the radius with a large splinter of the ulna
were removed. Irrigation with carbolized water was employed, and healthy
granulations gradually filled the wound. Passive motion was then used, and a
serviceable false joint, with good range and strength, was obtained. The short-
ening was four inches.
10. In an Address upon Empiricism, President Boyd of the Indiana Society,
hits several nails hard and square on the head. Legislation can do little, even
if obtainable, until the average of public intelligence and appreciation is elevated.
And no quackery is so harmful to the profession as that practised by members of
the regular ranks. The orator's exposure of the weaknesses of both physicians
and patients is peculiarly racy and vigourous.
Dr. Hervey suggests, with some judgment, steps that can be taken by the pro-
fession to secure such enlightenment of the people as may lead them to tolerate,
and even to demand, legislation for sanitary ends. Investigations of sanitary ques-
tions made by committees of the Society, reports of results, annually presented to
the Governor, and printed in a popular form for sale to the public at low prices,
together with teaching the rudimentary principles of public health in the schools,
are some of the means recommended.
Dr. Haughton examines at some length the nervous mechanism concerned in
vascular contraction and dilatation, and indicates the probable mode of action of
the drugs used to influence the distribution of blood.
Dr. J. I. Booker attacks with judicious vigour the indiscriminate use of the
1878.]
Transactions of State Medical Societies.
505
hypodermic syringe. No more than ourselves does he deny the very great value
of this form of medication, in special cases. In these it is certainly invaluable,
and cannot be replaced by any other mode of administration. Apart from the
many and grave objections to its unnecessary use by physicians only, the writer
notices the very curious but undeniable tact, that this apparently harsh method
possesses peculiar fascinations for invalids, and is constantly employed by them at
their own discretion. We have met two cases in which we sought in vain to in-
duce devotees to morphia injections to try to use the drug in the ordinary manner,
as a first step towards cure. One of them we convinced by experiment that the
stomach would duly absorb it. The other did not allege any inability on the part
of the stomach. Neither could give any definite reason for adhering to the syringe ;
and neither would abandon it. One employed it till the physical strength
became inadequate to the act, when death speedily occurred. We think the time
has fully come when all conscientious physicians should frown upon the habitual
and needless use of hypodermic medication.
11. In the Kansas Transactions, Dr. Schenck combats the "germ theory" of
septic diseases. The organisms to which these diseases are attributed do not
always precede the symptoms, as they should, if causative, but on the contrary
appear only after the disorder is fully developed. Infectious fluids have been
found to retain their virulence after bacteria have been removed; and bacteria,
separated from the fluid, have been found innocuous. Living germs or organisms
are also sometimes existent in the blood when the disease is not infectious. That
many remedies which kill germs do also cure septic disease does not prove the
assumed relation of cause and effect. In truth, antiseptic efficacy and destruc-
tiveness of germ life do not closely correspond, in different drugs. The fearfully
powerful virus of the rattlesnake, as shown by Dr. Weir Mitchell, contains, when
fresh, no visible organic life, and the flesh innoculated with it rapidly putrefies.
Chemical changes seem, to our writer, better to account for the production of the
different specific poisons than does the theory of germs.
In a report upon typho- malarial fever, Dr. Van Eman seems rather disposed
to doubt the specific entity of typhoid proper.
Dr. Sinks reports a case of congenital tetanus. The infant died twenty-four
hours after birth. It was born by a face-presentation, but not with a particu-
larly long or difficult labour. Rather violent movements had been felt a few
hours before labour. Death was apparently due to interference with respiration.
Multiple tumours of the dura-mater accompanied with absorption of entire
thickness of the cranium over them, abscess of the brain and hemiplegia, are re-
ported by Dr. H. S. Roberts. There was a strong tendency to wasting away of
bony tissue in other parts of the skeleton. The precise relationship between
these different phenomena is not altogether clear, and makes the case one of great
interest. The tumours, from one-eighth to four-eighths of an inch thick, were all
upon the left parietal region, except one over the right orbit. No sign of brain
irritation appeared connected with these. One only had produced slight depres-
sion. The left hemiplegia was attributed to the abscess, deep in the right hemi-
sphere. The tumours, six in number, are described as "fungous," " strawberry-
red" and "quite vascular." B. L. 11.
No. CL April 1878. 33
506
Bibliographical Notices.
[April
Art. XXXV. — Transactions of the Canada Medical Association. Tenth
Annual Meeting, Montreal, Sept. 12 and 13, 1877. Vol. I. Publication
Committee: Drs. David, E. Robillard, E. P. Howard, F. W. Campbell, and
Win. Osier. 8vo. pp. 244. Montreal, 1877.
In addition to the minutes of the annual meeting, list of officers and members,
and the president's address, this volume contains fifteen papers, generally short,
but on subjects of present interest to the profession, and of more than ordinary
merit.
The subject of the forensic relations of insanity, with special reference to the
Pimlico murder, is treated by Dr. Joseph Workman in a paper "On Crime and
Insanity," in which the details of several similar Canadian cases are given. This
is supplemented by one entitled the "Plea of Insanity in Courts of Law," by
Edward Hornibrooke, M.D., written to favour the principle of placing those
charged with crime, and in whose defence the plea of insanity is urged, under the
supervision of experts for sufficient time to enable them to determine whether the
culprit was insane or not at the time the crime was committed. This is a protest
against the prevailing practice in courts of law of requiring ordinary practitioners
to give expert testimony in cases of insanity, and of practically demanding that
juries shall decide as to the sanity or insanity of the culprit.
Dr. R. P. Howard contributes two cases of " Stenosis of the Tricuspid Orifice,"
with observations. In one of these the right auricle was dilated to such an extent
that it was large enough to contain a good-sized orange ; the cusps, by their fusion,
had formed an elliptical opening at the tricuspid orifice, but the mitral and aortic
valves were also diseased.
In a paper, by Dr. Geo. Ross, a typical case of Addison's disease is given,
with a careful report of the autopsy, by Dr. Osier. The suprarenal capsules
were found to be enlarged and the seat of extensive caseous deposit, with some
softening. This patient had none of the ordinary rational signs of anaemia, and
microscopic examination of the blood " proved that its cellular elements appeared
just as in health." The entirely negative results of this typical case, as regards
the condition of the blood, are referred to as wholly opposed to the theory of
Prof. Pepper expressed in his paper published recently in this Journal. A case
of Progressive Pernicious Anaemia of the Myelogenous Variety, with an autopsy,
is contributed by Drs. Bell and Osier.
A case of Supposed Gummy Tumour of the Brain in a child of three years,
followed by recovery — and papers on the Use of Acetate of Lead in Large Doses
in Post-partum and other Hemorrhages, and on Vital Statistics— complete the
medical articles.
In the surgical section, we notice papers on Various Wounds and their Treat-
ment ; on Ovariotomy ; Vesico- Vaginal Fistula ; Embolism of the Arteria Cen-
tralis Retinae ; on the Origin and Develojmient of the Epithelial Tumours of the
Anterior Third of the Eyeball, with some general remarks ; Optical Defects ;
and, finally, an illustrated article, by Dr. Fenwick, on Excision of the Knee-
joint, embodying the results of thirteen operations, and only one death, although
two cases of chronic diseases subsequently required amputation.
We regret that want of space forbids a more extended notice of some of these
papers, which are models of conciseness ; but if we were to single out any feature
for especial commendation, it would be the reports of post-mortem examinations,
which have been carefully conducted, and clearly and comprehensively recorded.
We would, also, have liked to refer pointedly to some of the paragraphs in the
able address by the President, Wm. H. Hingston, M.D. ; but space permits us
1878.] Transections of American Neurological Association.
507
only to refer to that part of it which treats of foeticide in its social, moral, and legal
relations. The alarming prevalence of this crime in the United States is com-
mented upon, and is declared to be "but the logical outcome of those theories of
genesis and of population which have betn so enticingly placed before us by some
very eminent scientists in latter years."
After reporting a case of a lady, "who came from the adjoining Union, with
shattered health and with head bowed down, who admitted, unreservedly, having
procured abortion in her own person fourteen times!", he permits his opinion
of the relation of the materialistic tendencies of the science of to-day to be in-
ferred from the following:- —
"When persons have learned to regard man, in embryo, as a mere aggregation
or union of fortuitous atoms, a plastic germ, a kind of colloid or protoplasm,
which the chemical and mechanical laws of attraction and repulsion, selection and
rejection, change and wave-like motion, may ultimately develop into a thinking
being, but little heed will be given to the integrity of that immature creature sus-
pended in the female womb If man derives his existence by a
process of evolution from a simple cell way up through the tribes of zoophytes,
lizards, and monkeys, cui malo, then, now and again, to hook an embryotic mass
from any part of that long living chain ? The bathybius or beetle, the codfish or
chicken, the mollusk or monkey, is but a link, and man is no more."
It is evident that the disciples of Malthus and of evolution have been detected
in their nefarious work of undermining the foundations of society, and they are
hereby warned to desist before they are overwhelmed by the rising storm of
popular indignation, or the entire superstructure comes tumbling about their ears.
Perusal of this first volume of the Transactions of the Canada Medical Asso-
ciation confirms the high opinion expressed by Prof. Bowditch, in his presiden-
tial address to the American Medical Association last year, when he spoke of the
former as " a body of physicians, all of whom have been educated under English
influences, and many of whom have pursued their studies in England, and have
received diplomas from the schools of that country," and "Ave all know the high
standard of qualifications required by the British schools."
Feeling that these encomiums are not only sincere, but also sustained by evi-
dence, we hasten to acknowledge this series as promising substantial gain to Ame-
rican medicine. F. W.
Art. XXXVI. — Transactions of the American Neurological Association for
1877. Yol. II. Edited by E. C. Seguin, M. D. 8vo. pp. lxi., 227. New
York, 187 7.
The papers read at the meeting of 1876 are included in this volume, as well as;
those of 1877, making twenty- two articles in all, on subjects of general interest to
the profession.
In the Inaugural Address, Dr. Jewell lays down a proposition, the truth of
which is becoming daily more and more appreciated. After calling attention to
the need of a more thoughtful study of the healthy anatomy and physiology of
the nervous system, and confessing that thus far comparatively little has been
done and made public in our own country towards advancing a knowledge of this
kind, he says, " with due respect to those who laboured in less favoured times, I
wish to see less reliance placed on the records of pathological cases as they exist
in the literature of the past." In other words, post-mortem results, as recorded
by incompetent and inexperienced observers, serve to retard rather than to ad~
508
Bibliographical Notices.
[April
vance science. With our present improved methods of investigation and broad
foundation of facts of normal anatomy and physiology, the progress of pathology
demands that an individual who undertakes to conduct an autopsy shall employ
these methods and be thoroughly familiar with normal anatomy, both macro-
scopical and microscopical. This is especially true in the pathology of the nervous
system, so much so that an eminent physiologist lately expressed the opinion
that in view of the conflicting facts that have been recorded, " the field must all be
worked over, and we must now begin de novo.,,
In Dr. Hammond's paper on the Odour of the Human Body as developed by
Certain Affections of the Nervous System, the observations arc based principally
on ex-parte statements of patients ; for instance, here is Case III. : "A lady
now under my charge informs me that whenever her emotions of anger are excited,
she and those near her are sensible of the fact that she exhales from the skin of
her head, neck, and chest a marked odour of pineapple," voila tout. The illus-
trations are, with a solitary exception, taken from the gentler sex, and vary from
rosaceous (amative), violaceous (hysterical), and pineapple (combative), all the
way to the odour of sanctity and Limburger cheese ! The observations of Dr.
Preismann, of Nicolaeff, regarding the odour of the breath after coitus is not referred
to, unless it is meant to be included in the rosaceous odour, whose existence is
sustained by the veracious testimony of a New York gentleman, who informed
Dr. H. that his mistress "gives off a very decided rosaceous odour at such pe-
riods."
If a new nosology is scented in the foregoing remarks, and a new specialty is
to be entered, it is evident that the Roman beak will again be in demand, and
that physicians with extraordinary olfactory facilities will have great natural
advantages in the way of diagnosis, not to speak of prognosis or therapeusis.
F. AV.
Art. XXXVII. — Transactions of the New York Pathological Society. Vol.
II. Based on the proceedings of the year 1875, and largely supplemented from
the records of 1844 to 1877. Edited by John C. Peters, M.D., President
of the Medical Society of the County of New York, etc. 8vo. pp. xvi., 291.
New York : Wm. Wood & Co., 1877.
We are glad to see that this volume enjoys the same advantage in its editorial
relation as the former, which was noticed in our number for July, 1877. Dr.
Peters, one of the constituent members of the Society, by his years of experience
is peculiarly qualified for the task of condensing and arranging the material stored
up in the archives of the association. In the two volumes that have thus far ap-
peared, this duty has been judiciously performed, and the practical value of the
work has been increased by the addition of notes giving in brief the present patho-
logical views on the different topics discussed. The number of rare and interest-
ing diseases represented by the specimens presented at the meetings of the Society
for the last thirty-four years, is very large ; and it is supplemented by a number
of cases which the enterprising members from time to time translated from foreign
journals and made the subject of reports to the Society ; so that the statement of
the editor in his preface is perfectly comprehensible, that, "In fact, it may
almost be said that no disease, however apparently unique, has not its counter-
part in our archives ; few so rare that we cannot produce several examples of
them ; whilst those which are generally considered infrequent can often be shown
by the score, or more."
1878.] Transactions of the New York Pathological Society. 509
The description of cases and the discussions are models of conciseness ; while
particularly interesting subjects, such as Portal Phlebitis, are selected for compre-
hensive reports from current literature.
As the former number was devoted to the consideration of cases of diseases of
the nervous system, and of the organs of respiration, circulation, and digestion,
so the present volume continues the latter topic by illustrations of diseases of the
stomach, pancreas, liver, and intestines.
The fact that many of these cases have been for several years the property of
medical literature, relieves us from the necessity of making extended note of them
at this time, while it does not detract from, but rather increases the value of, the
series as works of reference. A case of perforating ulcer of the stomach, which
opens the volume, although reported by Dr. Jancway in 1870, is of such present
interest that we are induced to give, in outline, the main details of the case.
A woman, 34 years of age, who had suffered from previous attacks of haemop-
tysis, and occasional fits of vomiting, was -seized, three weeks before her death,
with a chill, followed by fever, vomiting, and diarrhoea, and was admitted into
the hospital. She was very weak and occasionally vomited blood, and com-
plained of pain in the stomach, increased by food. She shortly died of asthenia.
Cheesy deposits were found in both lungs at the apices. The liver was fatty, and
a sac was discovered containing gas and a sour-smelling, black-coloured fluid,
with a slight amount of fine solid contents, situated in the epigastric and left hypo-
chondriac regions. The necrosed portion of the stomach was about half an inch
from the pylorus along the greater curvature, and was one inch in diameter. A
fibrinous plug was found in the gastro-epiploic artery, which ' ' looked very much
like an embolus, although there was no point to which it could be traced."
Had this abscess been recognized during life it would have raised an interesting
question of treatment, since it is well known that spontaneous perforation of the
stomach and abdominal wall by a foreign body has been followed by recovery ;
and gastrotomy, also, has frequently furnished equally favourable results. Since
these cases attract the attention of both physician and surgeon, it is to be regretted
that in the present record no microscopical examination of the walls of the vessel
involved has been contributed, and the presence or absence of incipient tubercu-
lization of the intestines and omentum, is likewise left for conjecture. No men-
tion is made of the condition of the endothelium of the heart and aorta, or even
of the cardiac valves, unless they are included in the general statement that ' ' the
other organs were healthy." Indeed, as a work on pathology, it lies broadly
open to the criticism of lack of system in recording examinations, particularly the
meagreness of the results of microscopical observation. In point of fact, material
of great practical value has been allowed to go almost fruitless, from the need of
careful study, intelligent and conscientious analysis, and systematic record ; for the
want of which the present series must come far short of its possible usefulness.
A committee on microscopy existed ; but apart from one brief report on page 42
(which has no apparent relevancy to the case whereto it is appended), we find no
other evidence of its existence, except among the list of officers and committees.
Mention of over three hundred cases is made, and some interesting tables are
given, including those of operations for ileo-cascal abscess, intussusceptions, and
of 258 cases of intestinal obstruction. Dr. Delafield contributed a tabular state-
ment of sixteen cases of perforation of the vermiform appendix.
Among the more interesting cases, we notice one of a man, 54 years of age,
where there was complete blocking up of the duodenum by gall-stones in such a
way as to prevent the passage of food from the stomach. No statement is given
as to the condition of the intestine. A case of congenital occlusion of the duo-
denum, with rudimentary and imperforate ureters ; one of death following incised
510
Bibliographical Notices.
[April
wound of intestine, possibly caused by a suture three inches in length, which, in-
stead of being cut off close, was allowed to dangle in the peritoneal cavity ; a
curious instance of peri-typhlitis and abscess in the left iiiac region, the caecum
having taken this position during an attack of diarrhoea, and afterward contracted
adhesions ; and several interesting cases of pin-hole perforation of intestine, lead-
ing to fatal peritonitis, are reported. A case of a girl of 17 is given, where there
was extensive sloughing of the bowels, about five feet of intestine being dis-
charged. The patient died four months later of emaciation. A polyp on the
peritoneal surface of the ileum was the supposed cause of the invagination. Inter-
esting cases of vesicointestinal fistule are also detailed, where lumbricoid worms
were discharged from the urethra, and various foreign bodies found their way into
the bladder. Hematoma of the pancreas occurred in a haemophile, with obstruc-
tive jaundice, and emaciation and deatli from asthenia. One case of ulcer of the
rectum was converted into a recto- vesical fistule by a dose of five cathartic pills,
given by a ••homoeopathic" practitioner. Lumbo-colotomy was performed, but
the patient died from pyaemia on the twenty-second day after the operation.
Y. \\.
Art. XXXVIII. — Public Hygiene in America. Being the Centennial Discourse
delivered before the International Medical Congress, Philadelphia, Sept. 1876.
By Henry I. Bowditch, M.D. With Extracts from Correspondence from
the various States. Together with a Digest of American Sanitary Law, by
Henry G. Pickering. Esq. lGmo. pp. 498. Boston. Mass. : Little, Brown
& Co. London: TrUbner & Co., 1877.
There is very little of the "spread eagle " quality in Dr. Bowditch's discourse.
Here, as in other of his efforts to elicit or to communicate truth, he makes great
use of the numerical method. A series of questions, skilfully devised to allow of
brief or even monosyllabic answers, was arranged to obtain exact information upon
the present condition of State preventive medicine. The subject is viewed from
the medical, the legal, and the social points of view — the questions covering nearly
all matters bearing upon the public health. Correspondents were selected so far
as was possible from among medical men known to be interested in sanitary
science. Only two territories, and no States, are unrepresented among the re-
sponses which serve as basis for this discourse.
Before presenting the results of his inquiries, however. Dr. BoAvditch sketches
the changing phases of medical opinion during the century. The period from
1776 to 1832 is characterized as an epoch of medical system-making, of blind
faith in drugs, and of utter overlooking of Xature's healing power. Then came a
time when doubt, exact observation of disease, and of the effect of drugs, began
to supplant the unquestioning adherence to tradition and to authority. As a
period of reaction, this was probably attended with a too great reliance upon
Xature's resources, and too great distrust of the medical weapons formerly so
revered. The introduction of the "numerical method" into the observation of
the course of diseases and the result of treatment, and the grand idea of the self-
limited character of many maladies, especially distinguish this epoch. The third
and present epoch is counted from the foundation of the first State Board of Health
in 1869- Preventive medicine can be truly such, on any considerable scale, only
through the co-operation of the people, or. in other words, the State, with the
medical profession. This present grand and hopeful era — while gradually leading
to a juster valuation of the precise scope and power of the healing art, and learn-
1878.]
Godikd, Stuttering and its Treatment.
511
ing to measure with exactness the methods by which drugs act. and the limits of
their efficiency — is yet pre-eminently distinguished as aiming rather to remove or
prevent causes of disease, than to treat the perfected results. And we doubt not
that Dr. Bowditch is right in predicting for preventive medicine an ever-growing
importance. *
The responses to circular letters of inquiry, as here collated, present a synopsis
of the progress and results of public hygiene and State medicine, as illustrated by
legislation, public opinion, professional views and measures, the teachings and
practice of educational establishments, in all sections of our country during its
century of national life.
Three-fourths of the volume is composed of appendices. One of these presents
copious extracts from the correspondence elicited by the circulars. "These excerpts
depict the opinions and customs of the people, and the local peculiarities, from a
sanitary point of view, of the districts inhabited by the writers. Another appen-
dix deals with hygiene and preventive medicine as practised and taught in schools
of various grades.
Henry G. Pickering. Esq., contributes a digest of the laws, national and State,
looking towards the health of the people. The legislation of each State is sepa-
rately presented from its admission to the Union to date of the preparation of the
discourse. Fifteen States have health boards — nominally, at least. What mighty
powers for good these maybe made is obvious to all who have become acquainted
with the work of the Massachusetts and Michigan organizations, as shown in the
reports noticed in former pages of this Journal. Pennsylvania has yet to add her
name to the list of States that acknowledge their obligation to protect the health
of their citizens by the best means yet devised.
The very important observations of Dr. Bowditch. as to the relations of soil-
moisture to consumption, form the subject of a brief chapter.
One or two other brief appendices go to complete this thoroughly earnest and
practical summary of American effort in sanitary science. Altogether, we find
here a reference book of permanent value. B. L. R.
Art. XXXIX. — Du Begaiement et de son Traitement Physiologique ; par le
Dr. Jules Godard. 8vo. pp. 64. Paris: J. B. Bailliere & Fils, 1877.
Stuttering, and its Treatment on Physiological Principles. By Dr. Jules
Godard.
This little pamphlet, commencing with a brief historical sketch of the theories
and methods of treatment of previous writers, is mainly an exposition of the views
of M. Chervin, of Paris, as to the nature of stuttering, with an account of his
method of treatment. Adopting M. Moutard-Martin's definition of stuttering as
an intermittent choreic state of the apparatus of phonation and respiration. M.
Chervin divides the subject into — I. stuttering during inspiration ; II. during
expiration; and III. either between or durin g both these periods. Then, since
the trouble in phonation and respiration may be complicated by various irregular
movements (of the jaw, tongue, lips, muscles of the face, neck, or even of the
limbs), he has subdivided each of the foregoing classes into those states in which
stuttering is and is not accompanied by grimaces, thus making a classification which
appears useless from a therapeutic point of view, since all classes are subjected
to the same treatment, while it is not sufficiently analytic or precise to be of phy-
siological value. The treatment recommended is dividedin to three stages. In
512
Bibliographical Notices.
[April
the first, that of respiratory- exercise, the pupil is taught by imitation, first to make
a long, full inspiration and follow it by a regular forcible expiration ; then the
respiratory movements are made with various rhythms until they become full,
regular, and easy, instead of being jerky, interrupted, and accomplished with evi-
dent effort and fatigue. In the second stage of treatment, exercises with the
vowels are substituted for the previous mute breathings, giving to each vowel the
various modifications of tone, pitch, duration, etc., in which they occur in ordinary
conversation. The third stage consists of exercises with the consonants, alone
and in combination with the different vowels, the correct position for the tongue
and lips being demonstrated for each letter of the alphabet; these exercises are
repeated at first slowly, then rapidly, varying the pitch and duration of each syl-
lable and passing from words of one syllable to those of two or more. Prepared
by these exercises, the pupil then learns to articulate, slowly and methodically,
short sentences, then periods, paragraphs, etc., separating each sentence, and
always commencing with a deep inspiration.
This system of treatment, of which we have given the outline, differs in no
important respect from that long employed, more especially in Germany, with
the exception of the fact that it only lasts twenty days. M. Chervin also, as
reported by Dr. Godard, differs from most others in giving an almost uui versa 11 v
favourable prognosis as regards cure and freedom from relapse, a result which
seems to be substantiated by the cases reported, although we could wish they were
a little fuller as to detail. Thus, in twenty-three cases occurring during one ses-
sion, freedom from relapse is only noted in six cases; they were all,. however,
with one exception, cured at the end" of twenty days. 11. M. S.
Art. XL. — Two Lectures on Convulsions and Paralysis as Effects of Dis-
ease of the Base of the Brain. Delivered by Prof. Browx-Sequard
before the Philadelphia County Medical Society, Feb. 15 and 16, 1878. Ste-
nographic-ally reported by Frank Woodbury, M.D., Keporting Secretary.
Pamphlet. Pp. 32. Philadelphia, 1878.
In the excellent report which Dr. Woodbury has furnished of these k-ctures is
to be found, in a matured form, the views which have been occupying the
attention of their distinguished author for a number of years. AYhile not
entirely novel to us, since Dr. Brown-Sequard has indicated in several recent
papers his gradual volution of the views here presented, this is the first opportu-
nity afforded us of appreciating the extended series of facts which can be brought
forward in their support. The points in the physiology and pathology of the
nervous system to which Dr. Brown-Sequard takes exception, theories which he
was mainly instrumental in erecting and which would alone entitle his later
observations to serious consideration, are first, that one side of the brain does not
move the opposite side of the body, and second, that the anatomical decussation
of fibres which is knoAvn to take place in the medulla is not a physiological decus-
sation, is not a crossing of the motor paths in the cord. Without attempting to
give even an outline of the grounds on which these theories have been dis-
carded, that which Dr. Brown-Sequard offers as their substitute is briefly, as fol-
io ws : —
First, that each side of the brain is sufficient to act on each side of the body,
but not through direct continuity of motor fibres ; secondly, that in certain tracts
in the base of the brain a very small number of fibres may be perfectly competent
1878.]
Ott, The Action of Medicines.
513
to transmit the orders of the will ; and, thirdly, that paralysis and convulsions,
instead of appearing from loss of function in the part diseased, will bear some
other explanation.
Under the influence of an irritation, starting either in the neighbourhood of or
remote from certain cells, and acting upon them, we may have the function of
those cells excited and thrown into action, that action depending upon the pro-
pert}- of the cells excited. As, for example, the irritation set up by disease of the
brain may be conducted to the place in the cerebro-spinal system restraining the
motor centre of one limb ; there will consequently be paralysis of that limb pro-
duced in the same manner in which either direct or indirect stimulation of the
vagus may paralyze the heart. In other words, all paralyses are caused by the
conduction of inhibitory influences from disease of a more or less remote point of
the nervous system to the motor centres of the part paralyzed. According to this
theory, all those perplexing cases can be explained, in which disease in a certain
portion of the brain may be followed in one instance by paralysis on the opposite
side of the body, in another, on the same side, in a third, on both sides, and in
another case, the disease being the same there may be no paralysis at all. This
variety of effect certainly cannot be explained as due to the interruption of con-
duction of motor impulses, for, according to such an anatomical explanation, the
same anatomical cause should invariably be followed by the same effect ; one such
exception should be enough to overthrow this explanation. On the other hand,
according to this theory of conduction through various channels of an inhibitory
influence, the variety of effect from one cause is only analogous to the different
effects produced by the exposure of different individuals to the same morbific
cause, a fact only to be explained as due to the special predisposition and suscep-
tibility of the individual. Again this theory of reflected irritation will alone ex-
plain the fact that section of the anterior columns of the cord is invariably followed
by paralysis, while section of their upward continuation, the lateral columns of
the medulla, is followed by no paralysis ; in fact, there is in the medulla no bundle
of white fibres which may not be divided without producing paralysis. As regards
the remaining view suggested, if it is admitted that only a very few fibres are
essential in carrying the motor impulses from the will, then it is not necessary to
suppose that these fibres go all the way from the brain through the medulla and
spinal cord to the muscles (a supposition rendered untenable by the fact that the
decussating fibres, which undergo degeneration after disease of the brain, are not
motor fibres, and have been traced to regions in the cord which contain no motor
paths), but that the primary exertion of the will sets into continued action
various nervous centres in the medulla and cord. R. M. S.
Art. XLI. — The Action of Medicines. By Isaac Ott, A.M., M.D., for-
merly Demonstrator of Experimental Physiology, University of Pennsylvania.
8vo. pp. 168. Philadelphia: Lindsay & Blakiston, 1878.
There are few departments of scientific medicine more worthy of attention, or
whose pursuit has been more fruitful in valuable results, than the study scientifi-
cally of the action of drugs on the lower animals. Setting aside the fact that by
this means alone are we able rationally to explain the modus operandi of drugs,
the advance which has been given to pure physiology through the study of the
actions of poisons, is almost incredible. To Bernard we are indebted for the
first application of this principle, and to his labours we owe the major part of the
514 Bibliographical Notices. [April
results obtained through this mode of investigation. In his studies of curare, car-
bonic oxide, sulphocyanide of potassium, etc., we have become acquainted with
some of. the most important laws and facts of physiology.
Through the experiments of Heidenhain with atropia we have learned the exist-
ence of the secretory nerves, properly so called, while to the investigations of Von
Bezold and Blobaum with the same drug, we owe the great part of our knowledge
of the cardiac functions of the pneumogastic nerves : in fact the present extended
knowledge which we possess of cardiac physiology is mainly due to the experi-
mentation of Schmiedenberg and others with drugs, such as muscarin, atropin,
nicotin, etc.
These then are some few of the facts in physiology acquired through the study
of the action of medicines ; though much has already been accomplished, there
still remains an extended, unbroken field, inviting study. " All poisons are capa-
ble of becoming, in the hands of the experimenter, vivisection instruments of the
greatest delicacy and importance." The advances also which have been made in
toxicology through the study of the antagonism of drugs is incalculable.
And yet, in spite of the importance of this field of investigation, the work
under consideration is the only one in the English language which can offer, with
any degree of completeness, that assistance and instruction so essential to the cor-
rect and successful study of pharmacology. In fact the only other work we are
acquainted with in any language that treats fully of this subject is Hermann' s
Lehrbvch der Experimental en Toxicologic, and this being in a foreign language
is inaccessible to many, while the work of Lauder Brunton, commenced in 1871,
has never reached completion, treating alone of the action of drugs on the circula-
tion. In the book before us, however, filling as it does this gap in medical lite-
rature, we have a work which cannot fail to be of the greatest value to the student
of pharmacology. From the pen of a man himself no novice in the subjects of
which he treats, it bears upon it the impress of reliability, due to the author's
own experiences, a virtue too often wanting in mere compilations of the works of
others. But while it is valuable as presenting a concise summary of the present
state of our knowledge as regards the physiological action of remedies, it will be
chiefly valuable to him who wishes himself to experiment.
The work is divided into four chapters. Chap. I., on " How to Study the
Physiological Action of Medicines," is occupied with a detail of all those minutiae
which are so essential to successful experimentation, and with an account of the
necessary apparatus with directions for their use, while on pages 23 and 24 is given
a short account of the main points in physiological anatomy necessary to the ex-
perimenter on the lower animals. In Chap. II., " On the Xervous System." the
author first gives a brief outline of the main points in the physiology of the nervous
system, and then passes on to the consideration of the method of experimentation
in determining the action of drugs on the various integral parts of this system, as
the brain and spinal cord, motor and sensory nerves, etc. In this chapter he also
considers the modes of studying the action of drugs on the muscles, a subject of
sufficient importance, we think, to be entitled to a chapter exclusively to itself.
In Chapter III., on the "Action on the Circulatory Apparatus," the best and
last of this section of his book, Dr. Ott gives an exceedingly clear and concise
account of that very difficult subject, cardiac physiology: indeed, this chapter
alone would serve to render his book of the greatest service to the student, so
apt to be puzzled by this subject. The method which he has employed here,
as well as in the previous chapters, of introducing under each heading details of
actual experiments, cannot fail to impress on the mind of the reader both the func-
tions of the organs experimented on and the characteristic action of the drug in
question, while the experiments themselves serve as models to those who wisli to
1878.]
Binz, The Elements of Therapeutics.
515
become original investigators. The remaining portion of the chapter is occupied
with the considerations of the methods of studying the rapidity of the circulation,
measurement of arterial tension, action of the vagi, accelerator nerves, action of
drugs on the bloodvessels of excised organs, and on the heart of the frog.
In Chapter IV., " On the Action of Mecficines," there is presented a brief state-
ment of the action of the various alkaloids and principal drugs on the lower animals
and on man in health and disease, with a bibliography of the more important works
on each subject. While we cannot but think that this portion of the work is
supplementary in importance to the chapters on the mode of studying the action
of drugs, it still presents in a concise form, though incomplete as to the number of
drugs, the accepted doctrines as to the action of each remedy. R. M. S.
Art. XLIL — The Elements of Therapeutics. By Dr. C. Binz, Professor
of Pharmacology in the University of Bonn. Translated from the fifth German
edition, by Edward I. Sparks, M.A., M.B. Oxon. 12mo. pp. 347. New
York: Wm. Wood & Co., 1878.
Tins book is a "clinical guide to the action of medicines," embracing many
of the modern views of therapeutics, together with a discussion of the physiological
operation of drugs, and a very full materia medica list. For its small size it
contains considerable practical information, and is arranged conveniently for
reference. The physiological data are introduced mainly as a basis upon which
to found a rational system of therapeutics, though in the case of the more im-
portant drugs sufficient space is allotted to this branch of the subject to make it a
prominent feature. In connection with this class of drugs some detailed and accu-
rate accounts of physiological action are given, among these may be instanced that
of alcohol and those of the group Antipyretica, including cinchona, salicylic acid,
and the mineral and vegetable acids. On the other hand, there are numerous
dogmatic statements which are open to criticism, and a noticeable disregard for the
opinions of other experimenters. Thus it is asserted that digitalis, in poisonous
doses, arrests the human heart in diastole; whereas experiments upon animals
show that the arrest occurs almost uniformly in systole. Again the power of
lessening the reflex activity of the spinal cord possessed by choral and bromide
of potassium is but remotely referred to, and the reader is left in doubt as to
whether strychnia produces tetanic convulsions by paralyzing Setschenow's
centres, or by directly stimulating the spinal cord, the latter mode of action hav-
ing been proved by the experiments of Van Deen. The therapeutical indications
are stated clearly, and, with a few exceptions, are in accord with the teachings
of the best authorities, while more than usual care is taken to point out the best
methods of administration to obtain the results desired. The materia medica list
includes many of the preparations which are peculiar to the German Pharma-
copoeia, together with all of those officinal in the British and United States
Pharmacopoeias. The strength of all the preparations and the ingredients of
those which are compound in nature are given. In the former particular many
errors have been made in the preparations of the United States Pharmacopoeia,
and sufficient uniformity has not been observed in giving both the English and
American officinal names, in cases of dissimilarity in this respect. Several sub-
stances are briefly considered, which, though used in medicine, have not yet
found a place in our ordinary text-books ; those most worthy of mention are
a3ther petrolei, fel bovinum purificatum, serum lactis, and pilocarpin.
516
Bibliographical Notices.
[April
The doses of the different medicines are correctly estimated, and are expressed
both in the terms of the metrical system and in those still in use in this country
and Great Britain.
The classification adopted is too general, many drugs having well-marked points
of difference in physiological operation and distinct therapeutical applications being
considered side by side. In fine, while the physician may, with advantage, add
this book to his library, it is deserving only of a qualified recommendation to the
student. L. S.
Art. XLIII. — Die Formen des Harnrohrentrippers vnd die endoskopischen
Befunde derselben ; von Dr. Jos. Grl^feld in Wien., aus d. Med. Jahrbu-
chern IV. Heft 187 7.
The Varieties of Urethral Catarrh and their Endoscopic Appearance. By Dr.
Jos. Grunfeld, of Vienna.
The endoscope is an instrument which, though possessing a certain value, is
hardly likely ever to come into general use. Few surgeons, and fewer general
practitioners are in a position to own or employ it. and the pain and annoyance it
gives the patient are often enough in themselves to counterbalance any good attained
by its use. But there is a field in which it may be made of service to the whole
profession. Such a field is that which forms the subject of the monograph before
us, in which are recorded with characteristic faithfulness and due regard to the work
and opinion of others, the endoscopic appearances in various forms of urethritis as
studied by Dr. Giiinfeld. The advantage of distinguishing between different
lesions, which may produce very similar external manifestations, Ave acknowledge
at once, and in these days of analysis and special study, welcome every effort such
as this to bring out the details of a subject which as a whole may prove misleading.
Dr. Giiinfeld divides urethritis into five classes, viz. : — ■
I. Urethritis Blennorrhveica. — In which there is acute inflammation of the mu-
cous membrane, with marked swelling, dark-red colour, profuse secretion, and
a tendency to bleed on slight provocation. This form may usually be diagnosed
from the condition at the orificium urethra?, which represents pretty fairly the
condition deeper down.
II. Urethritis Memhranacea. — By this is not meant the "croupous urethritis"
of certain authors, but a form in which there is less evidence of a high grade of
inflammation than in the preceding, less secretion of pus, less swelling of the mu-
cous membrane, and the presence, as characteristic, of a thin membranous exudation,
usually arranged in longitudinal streaks, which can be removed only with diffi-
culty, this being apt to be followed by bleeding. The symptoms which are
appreciable without the endoscope are marked oedema of the cutis penis, with in-
flammation of the lymphatics on the dorsum and finding in the urine the detached
membrane, in the form of leathery, tube-like casts.
III. Urethritis Simplex. — This maybe simply an hyperemia, caused by forced
coitus, or the long-continued use of instruments. In the worst cases the evi-
dences of inflammation are much less than in the first form.
IV. Urethritis Granulosa. — This term though not scientifically exact, is used
to designate a condition, first studied by Desormeaux. analogous to granular con-
junctivitis. In it the endoscope shows a limited, single area, of a dull red. velvety
appearance, with little pus, accompanied by rigidity of the walls and narrowing
of the lumen of the urethra. This is very often the lesion upon which depends
gleet, and is the usual source of stricture. But it must be noted that neither it
1878.]
West, On Hospital Organization.
517
nor stricture is, as Desormeaux thought, most frequent in the deeper portions of the
urethra. The external signs of this condition consist of localized tenderness or
pain, and the presence of small shreds in the urine ; without the endoscope it is
very difficult of accurate diagnosis.
V. Urethritis with Ulceration. — This Br. Griinfeld believes to be extremely
rare, yet describes phlyctenular or herpetic ulcers, those excited by mechanical
irritation, chancres, and chancroids.
A slight modification of this classification, so as to make the order I. Urethritis
Simplex; II. Urethritis Blennorrhoeica ; III. Urethritis Membranacea ; IY.
Urethritis Granulosa, and to omit altogether the form dependent upon ulcers,
would perhaps make the work more exactly what its title leads us to expect.
This, however, is of little moment in comparison with the practical merits of the
monograph, whose main points are stated above. C. W. D.
Art. XLIV. — The Treatment of Spina Bifida by a New Method. By James
Morton, M.D., Professor of Materia Medica, Anderson's University. 8vo.
pp. viii., 120. Glasgow: James Maclehose, 1877.
The treatment of spina bifida by a new means rather than a new method would
be the proper title of this book. Yelpeau, Brainard, Holmes, and others have used
iodine with fair success, but Dr. Morton, so far as the small number of cases go,
has added an apparently better means of using the iodine. He dissolves ten
grains of iodine, and thirty of iodide of potassium, in an ounce of glycerine and
injects from half a drachm to two drachms of this solution into the sac after with-
drawing about half of its contents, and he is careful to prevent further escape of
the fluid by the application of collodion and pressure: Glycerine is chosen as the
vehicle because of its slight diffusibility. The operation is repeated at intervals
of a few weeks. The results in the fifteen cases have been twelve recoveries,
and three deaths, and all of his own lumbar cases have recovered. This is cer-
tainly a very favourable showing in a disease which lias generally been deemed in-
curable, and should lead to a more extensive trial of the means he has suggested.
The book is handsomely printed, but is marred by occasional blemishes in proof-
reading. Thus "cyst" is spelled "cist" (p. 23), "grs." becomes uqrs." (p.
53), and probably even the printer's devil would have scarcely overlooked " Yel-
peare" (p. 12), which does duty for the name of the famous French surgeon.
W. AY. K.
Art. XLY. — On Hospital Organization, with Special Reference to Hospitals
for Children. By Charles West, M.D., etc. etc. 24mo. pp. 97. London:
Macmillan & Co., 187 7.
This little book, by a man long acquainted with hospitals, is characterized
rather by intelligent appreciation of things needed than by any particular!}' origi-
nal suggestions for their attainment. To American eyes the ordinary administra-
tive machinery of an English hospital appears somewhat ponderous, though indeed
the details vary considerably in different charities. There has appeared, how-
ever, of late years, a tendency — not yet very strong, but still real, and sure to
518
Bibliographical Notices.
[April
grow — towards a simplification of the processes by which the wealth of the bene-
ficent, living or dead, is made to succour the sick and poor of to-day. We are
sorry that Dr. West, while recognizing and welcoming this beginning of change
in his most conservative country, does not attempt a little more in the way of
helping it on. It seems to us that he might give a little more weight and pro-
minence to the position of " Director," insist on his being a resident, and, above
all, recognize the very great importance of making him invariably a medical
man. To such a superintendent, wisely chosen, we believe the entire control of
the economy and discipline of a hospital may be entrusted with the greatest benefit.
For the results of his management he would, of course, be accountable to the
"committee" or board which appoints him. With such an officer, we are dis-
posed to believe that the sub-committees here mentioned, the "medical" and
" house," may be dispensed with. All such officials as "housekeeper," "su-
perintendent of nurses," etc., should, of course, be strictly subordinate to him.
Considerable space is devoted to the "question of sisterhoods." As to en-
trusting the nursing to these orders, arguments and opinions pro and con are pre-
sented with such impartiality that it is hard to tell the writer's own view. To
placing the entire management of English hospitals in such hands, he is opposed.
Dr. West's views upon the individual qualifications of nurses are very sensible.
If a cultivated lady has leisure, and a call to devote herself to nursing, let her
become a hospital nurse ; but let her reach the higher positions only through ex-
perience and faithfulness in the lower. And after all, " the truest sympathy, the
most practised skill in nursing the poor will be found among the poor themselves.
Make the position an honourable one .... but do not foster the delusion that
those are best fitted for the work, or will do most good in it, who find or fancy
that there is no scope for doing their duty in that state of life ' to which it hath
pleased God to call them ;' " and who trade not on the talent entrusted to them,
but upon some other for which whim impels them to exchange it.
A few well-considered pages deal with training of nurses, as practised and
practicable in English he pitals, especially for children.
A training-school and lome for nurses, near and connected with a hospital, is
advocated, both for its educational benefits, and as a resource in emergencies re-
quiring additional care in the hospital.
Suggestions upon the details of nurse's work show much experience and close-
ness of observation. Valuable hints, too, concerning diets and the care of soiled
clothing, are briefly given.
The great perplexity of the age — the gratuitous treatment of out-patients — re-
ceives close attention from our author. By an apparently judicious set of regula-
tions, prescribing certain inquiries as to the pecuniary means of applicants, he
claims to have reduced the yearly beneficiaries of one out-patient department from
13,000 to 9000, without excluding worthy cases. Since his retirement from con-
trol of the hospital, however, his plan has been abandoned — seemingly on insuf-
ficient grounds.
We cannot but. deeply regret the unhappy circumstances which led to the
severance of Dr. West's connection with the Hospital for Sick Children — the
dream of his youth and the occupation of thirty years of his manhood, as he pa-
thetically calls it. Even yet, however, he would continue its benefactor, since
this little work is published for its benefit. B. L. R.
1878.] Eeport of the State Board of Health of California.
519
Art. XLYI. — Fourth Biennial Report of the State Board of Health of
California. For 1876 and 1877. 12mo. pp. 92. Sacramento, 1877.
i
Had this Board achieved no other result, its action in regard to smallpox would
alone have amply proved its value. Upon the outbreak of this disease in San
Francisco in May, 1876, a supply of fresh bovine lymph was obtained from the
vaccine farm in Wisconsin. This was distributed gratuitously among the physi-
cians of the city and State. Of the three hundred and seventy-seven deaths
recorded, only thirty-two were outside of San Francisco. Considering the con-
stant currents of travel from this centre towards all parts of the State, we have
no doubt that the Board prevented, by the action noted, and by its judicious
measures for isolation, a very much more extended epidemic.
As in the Atlantic States, the summer of 1876 was characterized by extra-
ordinary heat. Deaths by sunstroke, hitherto almost unheard of, and a marked
increase of cholera infantum, were among its results.
Diphtheria was prevalent, and contagious ; it especially prevailed among the
filthy and unwholesome abodes of the lowest classes. Some hundred and fifty
or more deaths from this cause occurred in San Francisco, with a population of
288,000.
The great problem of caring for the sick children of the very poor, and espe-
cially for those children that have been abandoned at birth, meets with thoughtful
attention. The idea of a sanitarium, in some of the many salubrious sites of easy
access from the city, where pure milk might be more than an abstraction, and
all surroundings wholesome, where provision could be made for the proper classi-
fication and treatment of the various sorts of needy and suffering children, is sug-
gested as an experiment worth making.
The relations of the various California climates to .the development or arrest of
phthisis, are set forth at some length by Dr. Hatch,. the Secretary of the Board.
While little doubt exists as to the good effect of residence in certain of the coast
towns, and certain more elevated districts, upon persons in the earlier stages of
the disease, no encouragement is held out to expect benefit in advanced con-
ditions.
Another writer desires that a hospital for consumptives be established by the
State in a favourable location.
It may be that adulteration of food and drink is carried further on the Pacific
coast than in this part of the country. Still, we can hardly swallow " specimens
of whiskey" containing forty per cent, of "methyl, or methy lie alcohol, or wood-
spirit, besides common alcohol and a sufficiently large quantity of fusel oil to
render it liable to produce insanity, among other injurious effects." Such loose
and extravagant statements bespeak fanaticism rather than the scientific spirit.
What is the percentage of fusel oil liable to cause insanity,. " among other" ills?
We believe the present writer is not responsible for originating the absurd notion
that "ginger ale" is a fraud, because, forsooth, it is not an ale at all, — although
he repeats the complaint. There is just the same ground for indignation in this
case, that exists in regard to the "root beer" of our grandmothers, and no more.
No one ever pretended that either article had undergone alcoholic fermentation ;
and the one like the other is expressly designed and understood to be a beverage
wholly devoid of power to intoxicate. B. L. R.
520
Bibliographical Notices.
[April
Art. XLVIL — Report upon the Census of Rhode Is! and, 1875; with the Statis-
tics of the Population, Agriculture, Fisheries and Shore-Farms, and Manufac-
tures of the State. By Edwin M. Snow, M.D., Superintendent of the Cen-
sus. 8vo. pp. clix. and 159. Providence, R. I., 1877.
To all interested in statistical work, or desirous of studying any one of the sub-
jects embraced in the scope of this State census, we can safely commend I Jr.
Snow as a trustworthy guide and teacher. Many years of constant practice in
this kind of labour have taught him that most difficult art, the interpretation of
statistics, and also given power to distinguish at a glance the presence of error or
uncertainty in particular classes of returns.
We propose here to notice only a few scattered points, possessing some interest
from a medical point of view.
The population of African descent does not maintain its numbers in New Eng-
land at large, and barely so in Rhode Island. Recent increase in the absolute
number living in Rhode Island is chiefly due to immigration from the South. In
no northern State has their social and political standing been better, or as good.
Climate seems to be the cause of the heavy death-rate prevailing among them,
even in this State, which is warmer than most.
Dr. Snow's presentation of the facts as to the parentage of population at dif-
ferent periods continues to possess very great interest and importance. For
though, as he says, children born on the soil are technically Americans, yet in
many momentous aspects a large proportion Avill retain the characters of foreigners.
In the last ten years, population of American parentage has increased 12.89 per
cent., against that of foreign parentage 80.11, and mixed 39.61 per cent. Allow-
ing these rates of increase to have continued, a majority of the citizens are to-day
of foreign parentage.
Commenting upon tables showing numbers of persons living at different acres,
the visible effect of the civil war is pointed out, in diminishing the children under
five years, by the census of 1865, and those from five to ten in 1870, and ten to
fifteen by the present census. "It is easy," says the writer, "by study and re-
flection, to clothe columns of dry figures with a living interest."
Living at the age of 90 years and over, are reported 163 persons. The highest
figures, not commended to absolute belief however, are 120, 107, 106, 104, etc.
The third named was a white American, the first, coloured, and second, Irish.
As having a most important bearing upon the revolution which is in progress
in the character of population, a table for the city of Providence shows, for 9159
American- born matrons of child-bearing age, 1227 children born in 1875, against
4335 Irish matrons with 948 births. Thus in the same year and the same age-
period, we have 7.46 as the ratio of American matrons to each child born, and
4.57 as the proportion of Irish mothers to their infants. British matrons occupy
an intermediate position. The Germans nearly equal the Irish in fertility, though
their numbers are absolutely very much smaller. Such figures have a most pain-
ful significance.
The large number of children absent from school excites the more alarm, as
they are from the classes most needing the elevating effects of education. Viola-
tion of the laws against employing children in factories, and the avarice of parents
in working them from the earliest possible period, are largely responsible for this
state of things. Besides growing up in ignorance, these children are deplorably
injured in health and development. A most earnest protest is made against the
terrible cruelty thus perpetrated. We trust that, hereafter, attempts will be made
at least to enforce the existing laws, which wholly forbid factory work to children
under twelve years, and allow only limited work, with prescribed schooling, to
those from twelve to fifteen. B. L. R.
1878.]
521
QUARTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES
IN THE
MEDICAL SCIENCES.
ANATOMY AND PHYSIOLOGY.
The Functions of the Retina.
The determination of the functions of the retina, in regard to the perception of
magnitude and of colours, has been of late exercising some excellent experimenters
and ophthalmologists, and the results at which they have arrived may here be
shortly given ; and it is not uninteresting to follow the various methods that have
been adopted with the same object in view.
The sharpness or acuteness of vision in different parts of the retina — that is to
say, its power of distinguishing minute objects — has been investigated by various
observers. Lundberg's researches were undertaken with a view of determining
the degree of acuteness in the immediate vicinity of the blind spot or point of
entrance of the optic nerve. This was first roughly determined, and then squares
of white paper of one-fiftieth, one-twenty-fifth, one- twelfth, and finally one-half
of an inch in the side, were placed in a position nearly corresponding to the centre
of the blind spot, and, with the aid of a Forster's perimeter, provided with a
millimetre scale, slowly moved in all directions outwards. The first appearance
of the angle of the square was noted, and a figure was thus constructed from which
the diameter of the blind spot could be estimated. It was found that there was
a difference in the figures obtained with the large and the small squares, the size
of the blind spot appearing to be greater with those of one-fiftieth of an inch, and
smaller with those of one-half inch on the side. Thus, with the former the verti-
cal diameter of the blind spot of the right eye was estimated at 2.064 mm., and
its horizontal diameter at 1.425 mm., whilst with the half-inch squares the hori-
zontal diameter was 1.27 7 mm. and the vertical 1.298 mm. The difference be-
tween the two horizontal diameters was thus 0.148 mm., and of the two vertical
diameters 0.766 mm. The sensitiveness of the retina near the blind spot is evi-
dently, therefore, less above and below the entrance of the optic nerve than on
either side. The figures obtained presented some irregularities and projections
which were found to correspond to the position of the retinal bloodvessels.
Observations of a somewhat similar character were undertaken by Hen, who
used letters of various size instead of squares, and found that the acuteness of
vision at the margin of the yellow spot diminishes to one-half or even to one-third
of that possessed by the fovea centralis, though on passing beyond the limits of
the macula lutea the diminution takes place much more slowly. The breadth of
No. CL April 1878. 34
522
Progress of the Medical Sciences.
[April
the zone in which, by unpractised eyes, letters can be distinguished, differs in the
different meridians, and naturally to some extent in different persons. Jt is
greatest in the outer parts of the field of vision, which corresponds of course to
the inner part of the retina ; next in the inner part of the field, then in the lower,
and least of all in the upper part. Small letters near the eye are read at a greater
distance from the fovea centralis than large, but more distant letters under the
same visual angle. Practice, it is interesting to observe, made a great difference,
though not equally in all directions. Thus, in the horizontal meridian, and ex-
ternally, the breadth of the zone in which large letters could be read improved by
practice from 45° to 80°, no less than 35°, in the inner part of the field from 38°
to 55°, in the upper part of the field from 30° to 45°, and in the lower from 32°
to 50°. This improvement, it is to be observed, simply affected the recognition
of letters, and bore no reference to the perception of light, which remained unal-
tered by any amount of practice.
The latest observations that have been published on this subject are by Augustin
Charpentier, in Brown- Sequard's Archives de Physiologie. This observer used
a square composed of nine black dots, each having a diameter of l.G millimetres;
and, having seated himself before a Forster's perimeter, and fixed the central
spot of the instrument, he caused the square to be slowly moved outwards along
different meridians till the dots could no longer be separately distinguished. The
direction of the movement of the square was then changed, and it was brought up
towards the eye, but at the same angle, till the dots could again be distinguished.
It was found that, whilst, when the square was directly looked at, the dots could
be distinguished as separate at a distance of 3.50 metres, or nearly 11£ feet ; at an
angle of indirect vision so small as 5°, they could only be recognized as separate
at about 1.50 metre, or 5 feet; at an angle of 10° at 3 feet ; whilst at an angle of
30° the square had to be approximated to a distance of less than 10 inches in order
that the several dots might be distinguished. From all these experiments, there-
fore, the same conclusions may be drawn that the sharpness of vision is very great
at the yellow spot, but falls with great rapidity immediately beyond it.
Another point of interest that has lately been investigated, though there is some
discrepancy in the statements, is the sensitiveness of different parts of the retina
for different colours. Dobrowotsky, a Russian observer, finds that if the same
illumination be given to disks of different colours, which is difficult to manage in
practice, and these are gradually moved towards the point of fixation of the eye
along different meridians, white, and, coincidently, blue, are first perceived in all
parts of the retina, then green, and finally red. Chodin, on the other hand,
though admitting that the various colours undergo some change of tint when seen
by indirect vision, yet thinks that all colours can be recognized up to the most
extreme limits of the retinal field. AVoinow, again, speaks very definitely of the
existence of three zones of perceptivity in regard to colours around the macula
lutea. In the first, immediately surrounding this spot, all colours appear less
saturated than in the centre, some of them being apparently ' ' bluish' ' or " yel-
lowish," constituting what he terms relative red and green cecity. In the second
zone only yellow and blue are distinguished — his zone of absolute red and green
cecity ; mixed colours seen with this zone appear pure yellow if, when seen with
the fovea centralis, they seem to contain much yellow or pure blue ; if with cen-
tral vision, they seem to have much blue in their composition. In the third, or
outermost zone, perception of light remains, but no colour can be recognized.
This zone, therefore, represents that defect of vision which sometimes affects the
whole retina, and is termed achromatopsia, the play of colour being unperceived.
From these observations Woinow is led to admit the existence of five different
elements in the human retina — one, the rods, having for their function the per-
1878.]
Anatomy and Physiology.
523
ception of light alone ; and four kinds of cones, each adapted to perceive a funda-
mental tint — red, yellow, green, or blue — but having a very different distribution.
In and near the centre all are present, though even in this zone the red are less
numerous peripherally than centrally,. In the second zone, in addition to the
rods, only yellow and blue percipient cones are present, whilst in the third zone
the rods, or light-perceiving elements, alone remain. Woinow remarks that the
red and green perceiving elements are very tender and delicate, and are the first
to fail in function when the eye is injured, as in cases of contusion, whilst the
yellow and blue perceiving elements are more resistant, and no case of their ab-
sence has hitherto been recorded. Klug's observations, which have been pub-
lished in Graefe's Archiv, agree with those of Woinow, except that he makes a
fourth zone within Woinow' s red zone, in which only orange and violet are clearly
perceptible. — Lancet, Feb. 2, 1878.
On the Colouring Matter of the Retina in its Relation to Vision.
The discovery of the so-called "retina-red" or "retina-purple" by Boll, has
led to the adoption, by some authors, of the hypothesis that the chemical pro-
ducts resulting from the decomposition of the retinal pigment by light, stimulate
the terminations of the optic nerve ; and that this photo-chemical process is an
essential factor in ordinary vision. Kuhne has set himself to show that this
hypothesis is, to say the least, premature (Untersuch. aus dem physiolog. In-
stitut in Heidelberg, Band i. Heft 2). He points out that the retina of many
birds and reptiles, whose faculty of seeing is beyond question, contains no pur-
ple ; and that this is likewise true of the most sensitive portion of the human
retina — the fovea centralis and its immediate neighbourhood. The large retinal
rods of the river cray-fish contain a great deal of pigment ; but this is singularly
indifferent to the action of light, exposure to the sun's rays for several hours fail-
ing to bleach it. From these considerations it is clear that the retinal pigment
cannot be essential to vision in all animals ; while, from its indifference to light
in some of the invertebrata, it would almost seem to be analogous to the other
varieties of colouring matter, so often present in different parts of the eye, e. g.,
the yellow of the macula lutea, the coloured oil-drops in birds and reptiles, the
yellow of the lens in many fishes, the orange protoplasm recently discovered by
Dr. Ewalcl in the anterior layers of the cornea of the perch. The following ex-
periments show that in the frog, whose retinal rods contain a very sensitive kind
of purple, the power of distinct vision, and the faculty of distinguishing colours,
survive complete bleaching of the retina by direct sunlight. Frogs exposed to
the sun for more than an hour (the retina is quite decolourized by exposure for
fifteen minutes) were found to be able, not merely to elude all attempts made to
lay hold of them, but also to capture flies ; blind frogs, of course, being unable to
do either the one or the other. Again, if a number of frogs are confined in a
shallow dish, one-half of which is roofed with green, the other half with blue
glass, they will, in a short time, be found huddled together under the green por-
tion of the roof. This preference for green over blue is exhibited by a vast ma-
jority, both of Rana esculenta and R. temporaria. Possible fallacies which
might arise from the unequal diathermancy of the two kinds of glass, unequal
intensity of illumination, etc., were carefully eliminated. It was conclusively
ascertained that the preference was connected with the colour, and not with any
other property of the glass. Having settled this point, Kuhne introduced a num-
ber of blind frogs into a vessel of this sort, and found that they showed no pref-
erence for one part of it rather than another ; while frogs that had been exposed
to the sun for hours, and whose rods no longer contained any trace of purple,
speedily took refuge in the green half of their prison-house. — London Med.
Record, Dec. 15, 187 7.
524
Progress of the Medical Sciences.
[April
MATERIA MEDICA AND THERAPEUTICS.
Thymol; the new Antiseptic.
A rival to carbolic acid has certainly been discovered in thymol, the essential
ingredient of the oil of thyme, which is prepared either by treating the oil of
thyme itself with a strong alkaline solution, skimming off the thymene and cymol,
which separate and rise to the surface, and precipitating the thymol which remains
in solution with hydrochloric acid ; or else (and this appears to be its most com-
mon commercial source at present) by distilling the seeds of Ptyckotis ajowan —
an East Indian umbellifer, which contain from 5 to 6 per cent, of their weight of
this body. Thymol was discovered, according to Lewin, in 1719, by Caspar
Neumann. Its chemical properties were first examined in detail by Leonard
Doveri and by Lallemand ; and its antiputrescent properties were first distinctly
pointed out by Bouillon and Paquet, of Lille, in 1868, though they only used it to
deodorize unhealthy wounds, and did not attribute any antiseptic properties to it
in the present surgical sense of the word. These properties were first definitely
recognized, in 1875, by Dr. L. Lewin, of Berlin (Centralblatt Med. Wiss., No.
21, 1875, and Virchow's Archiv, Band lxv., s. 1G5), and by Husemann and
Valverde (Archiv fur Exper. Path., Band iv.). Lewin, who worked in Profes-
sor Liebreich's laboratory, showed experimentally that solutions containing one
part thymol per 1000 absolutely arrested saccharine fermentation ; and that they
powerfully retarded lactic fermentation, and checked various processes of decom-
position, even when used in relatively small quantities. Lewin also first pointed
out the comparative harmlessness of thymol internally administered ; the absence
of digestive disturbance after taking it, and its effect in checking abnormal fer-
mentation in the stomach. He further directed public attention to the probable
future of the drug as an antiseptic. Husemann's experiments, which were chiefly
made on rabbits and frogs, went to show that thymol is ten times less poisonous
to the organism than carbolic acid, and that hence in the quantities ordinarily
used for antiseptic purposes it may be considered as entirely innocuous. He fur-
ther showed that thymol is a far more powerful antiseptic than carbolic acid, that its
local application to the skin either as such or in saturated solutions had no irritant
effect whatever, and that in animals poisoned by excessive doses gastric erosions
never occurred as they do in carbolic acid poisoning, but that, on the other hand,
nephritis with albuminous urine and extensive fatty degeneration of the liver are
nearly constant phenomena in these cases.
At present it is as an external antiseptic that thymol claims the earnest attention
of the followers of Lister. The success which has attended its introduction into
Professor Volkmann's clinic at Halle, as described by his assistant, Dr. Hans
Ranke, in No. 128 of Volkmann's Sammlung Klinischer Vortr'dge,1 is striking
in the extreme, and we propose here to bring before our readers the method em-
ployed and the results obtained. In the main the general features of Lister's
antiseptic dressing were retained by Ranke, thymol being substituted for carbolic
acid with the single exception of the ligatures used for arresting hemorrhage and
deep sutures, which were always made with carbolized catgut. Since thymol is
not entirely soluble in water in the proportion of 1 to 1000, the following formula
was, after the first few trials, exclusively used for antiseptic purposes : Thymol,
1 gramme; alcohol, 10; glycerine, 20; water, 1000 grammes. This "thymol
solution," as it may be called for brevity's sake, has no corrosive action on in-
1 11 Ueber das Thymol und seine Benutzung bei der antiseptisclien Behandlung der
Wunden."
1878.]
Materia Medica and Therapeutics.
525
struments immersed in it, and in this respect is superior to solutions of carbolic,
and still more of salicylic acid. It causes, however, when sprayed over the hands
of the operator, a lively sensation of burning, accompanied with redness of the
skin ; but otherwise has no irritant Qualities. Anaesthesia of the skin and epider-
mic desquamation, both of which are liable to occur under the use of carbolic
acid, were never once observed in the case of thymol, nor did it exert any irritant
action on the respiratory organs. The gauze bandages used for Lister's dressing
were composed of the following materials : 1000 parts of bleached gauze, 500 of
spermaceti, 50 of resin, and 16 of thymol, spermaceti being substituted for paraffin
as a non-irritant, its object, however, being the same — namely, to retard the
evaporation of the somewhat volatile thymol. In these proportions the gauze is
extremely soft and pliant, it can be accurately adapted to a wound, and "sucks
up " (to use Dr. Ranke's own expression) "blood and the secretions of the wound
like a sponge." Owing to the impregnation of its fibres with spermaceti and
resin, they are unable to absorb the fluid, and, as the latter distributes itself only
in the meshes of the tissue, the bandage retains its elasticity in a high degree,
even when thoroughly soaked. This thymol-gauze was directly applied to the
wound, no "protective" being necessary, owing to the non- irritant quality of
the thymol. Between the seventh and eighth external layers a piece of gutta-
percha paper previously washed with thymol solution was inserted in place of the
ordinary hat-lining, and the whole was firmly fixed to the body with a gauze
roller soaked in thymol solution, and tightly drawn, so as to seal up the parts
almost hermetically against the outer air. Under these conditions very little
thymol evaporates, and even at the end of eight days a very strong smell of
thyme is perceived on removing the bandage. The thymol-gauze should be kept
in stock wrapped in parchment paper, which should only be opened at the moment
of using. The bandage must be removed and renewed as often as the least trace
of secretion reaches its surface ; but this necessity arises very much less frequently
than in the case of Lister's carbolic dressing. In no instance, however, was the
same dressing allowed to remain unchanged more than eight days. On those
parts of the body to which it was difficult to adapt the dressing, the edges of the
bandage and any other apparently weak points were strengthened with strips of
benzoic wool.
On the whole, from the summer of 1§77 up to January 23, excluding a num-
ber of slight injuries and trifling operations, thymol had been used in fifty-nine
operations in Volkmann's clinic with the most excellent results. In the first
forty-one cases the secretion was serous in only eight, and purulent in two. In
the remainder there was absolutely no secretion — that is to say, when the band-
age was removed, the skin of the protected parts was found completely dry, and
not a drop of liquid could be squeezed out of the layers of gauze. This first
series of thymol dressing includes cases of amputation of the mamma, of the
arm, of the foot by Chopart and Pirogoff's operations, three amputations of the
leg, four excisions of the elbow, two radical operations for hernia, and seven radi-
cal operations for the cure of hydrocele by excision. The sixteen severe opera-
tions treated with thymol during January of the present year include, inter alia,
a gunshot wound of the knee-joint treated by drainage of the joint, a secondary
amputation of the thigh, an incision of the hip, and also one of the knee-joint for
scrofulous caries, and an excision of the shoulder in an old case of dislocation of
the humerus complicated with fracture, in all of which the results obtained were
equal to those of the first series. Lastly, we should mention the successful ter-
mination of three ovariotomies performed by Professor Olshausen, and treated
throughout on antiseptic principles by means of thymol dressings.
To sum up Dr. Ranke's observations on the use of thymol, we may say that
526
Progress of the Medical Sciences.
[April
nearly all the major operations of surgery have been treated by him successfully
by the thymol modification of Lister's method; and although at present the in-
troduction of thymol offers no hope of any relaxation of the minute attention to
details which a successful carrying out of this method invariably necessitates, yet
since the secretion of wounds treated by thymol is much less, and their rate of
healing much quicker, than when carbolic acid is used, thymol deserves the pref-
erence over the latter, the results obtained with it (antiseptically considered)
being, to say the least, equally good. An additional advantage of thymol over
carbolic acid consists in its innocuous effects on the system at large, and in its non-
irritant action on parts to which it is locally applied. Thus, on the one hand,
permanent antiseptic irrigations with thymol solution (1 per 1000), which cannot
be carried out with carbolic acid for any length of time, have been repeatedly ami
successfully used in Professor Volkmann's clinic; and, on the Other, the red-
ness of the skin, vesication, and eczema produced by carbolic acid dressings have
entirely disappeared on the substitution of thymol for it.
At present one kilogramme of thymol costs, in the German market, sixty
marks (£3), whereas carbolic acid costs a little more than three shillings per kilo-
gramme, so that, at first sight, the expense of thymol dressing appears to be very
great. If, however, as Dr. Ranke clearly shows, we take into account the reduc-
tion in the number of bandages rendered possible by the use of thymol, owing to
the extremely small amount of secretion induced by the new antiseptic, the differ-
ence in price is much more than compensated for. Thus, to give a single example of
the superiority of thymol, we may mention the fact that two cases of diffused
ganglion of the palm, treated by incision, only required fr\vo changes of bandage
instead of eight or ten, as they would under the ordinary Lister's treatment.
The internal use of thymol in various diseases has at present scarcely answered
to the expectations which were formed of it. Experimented with on a large
scale by Coghen, of Cracow, it only relieved the symptoms in a case of chronic
gastric catarrh accompanied with fermentation ; whereas, in a number of cases of
acute and chronic gastric and intestinal catarrh, in intermittent fever, chronic
cystitis, typhoid fever, pneumonia, pulmonary phthisis, and chronic bronchitis, it
completely failed. As an antipyretic, in doses of two to four grammes (Baelz),
its action is also far inferior to that of salicylic acid ; hence, for the present, at
any rate, it is for its valuable antiseptic properties that thymol deserves to be at-
tentively studied ; and there can be no doubt that Dr. Ranke' s experience offers
every encouragement to antiseptic surgeons to introduce it largely into their
practice. — Med. Times and Gaz., March 2, 1878.
On the Mydriatic Properties of Duboisia Myoporoides, with an Account of its
General Physiological Action.
Mr. John Tweedy, Clinical Assistant at the Royal London Ophthalmic Hos-
pital, and Dr. Sydney Ringer, Professor of Therapeutics at University College,
London, have recently studied (Lancet, March 2, 1878) the physiological proper-
ties of duboisia, which belongs to the group of salpiglossideas, and occupies a
position intermediate between solanacea? and scrophulariacea;. Now, however,
it is definitely referred to solanacea?, notwithstanding its (duboisia' s) didynamous
stamens. It is indigenous in New South Wales, Queensland, and New Cale-
donia.
Its botanical relations naturally suggested that its alkaloid is probably similar,
if not identical, with atropia. These investigations confirm this surmise. Thus it
is found that, like atropia, duboisia dilates the pupil, dries the mouth, arrests the
secretion of the skin, produces headache and drowsiness. It also antagonizes the
effect of muscarin on the heart, and after some days excites tetanus in frogs.
1878.]
Materia Medica and Therapeutics.
527
Its action on the pupil is more prompt and energetic than atropia, and certainly
very much more so than the strongest extract of belladonna. In order to deter-
mine more clearly the rate and amount of its action upon the accommodation,
Mr. Tweedy determined to use his own eye, and gives the following account of
his experiment : "T first carefully tested the state of vision, and found that I
could read No. 1^ of Snellen's type distinctly from 4 in. (nearest point) to 21 in.
(furthest point) and V=fg-. I then placed a single drop of a solution of the ex-
tract (1 in 20) within the lids of the tested eye. A little lachrymation followed,
but no smarting. Exactly ten minutes afterwards the pupil began to dilate, and
the sight became rather misty for near objects. When once started, dilata-
tion proceeded very rapidly, so that fifteen minutes after instillation the pupil
was widely dilated, and the nearest point had receded to 10 in. In twenty- five
minutes 1 i Snellen could not be read at any distance by the unaided eye, and
the accommodation was therefore, for all practical purposes, completely paralyzed.
By more elaborate tests I discovered that the effect of the extract went on in-
creasing for four hours, when it attained its maximum. Twenty-four hours af-
terwards there was no appreciable amelioration, either in the pupil or in the
accommodation, but within the next twenty-four hours the effects began to pass
rapidly off, so that forty-eight hours after the instillation I could see l^- Snellen
from 5 j in. to 21 in., although the pupil was not much smaller. In seventy- two
hours, by an effort of accommodation, 1^ Snellen could be seen at 4^ in., and
the pupil was rather smaller, and reacted slightly to light. From this time the
accommodation became stronger and more active every hour, and the pupil
gradually diminished until it reached its natural size. Four days after the appli-
cation the accommodation was restored, and three days later the pupil was active,
and of its normal size.
' ' I could not at any time detect any change in the actual or relative strength of
the extra-ocular muscles.
' ' Experience having shown that the application of the extract was not likely to
be harmful to the eye, I resolved to employ it in all cases in which atropine was
indicated. I have therefore used it largely in injuries and diseases of the cornea,
in iritis, in spasm of accommodation, and whenever it has been necessary to para-
lyze the accommodation. Its action has in all instances been beneficial, and in
some cases I have been tempted to believe superior to that of atropia."
The Action of Diuretics.
According to Grutzner (PJiuger's Archiv, xi., 370) there are two distinct
modes by which the secretion of the kidney can be increased medicinally — (1)
by raising the pressure in the arterial system generally, e. g., by digitalis or
strj-chnia; and (2) by directly influencing the secreting tissues of the organ, e. g.,
by urea or nitrate of soda. If the blood-pressure in the arteries be lowered in
rabbits or dogs by dividing the cervical portion of the spinal cord, and so destroy-
ing the controlling effect of the vaso-motor centre in the medulla oblongata, the
urinary secretion almost completely ceases. If, however, urea or nitrate of soda
be injected into the veins, there is a slight rise in the blood-pressure, and the
kidneys recommence secreting under a pressure far below that at which they ordi-
narily secrete. The above drugs have the same effect if the blood-pressure is
lowered by large doses of chloral hydrate or curare. This action of urea and
nitrate of soda on the renal secretion appears to be of a "specific" character,
and to be in some way connected with the function of the Malpighian tufts. It
can be prevented by stimulating the medulla oblongata by electricity or by car-
bonic acid poisoning, and so raising the blood-pressure throughout the body ; for
this induces vaso-motor nerve spasm, contraction of the renal arterioles, lowered
528
Progress of the Medical Sciences.
[April
blood-pressure in the glomeruli, and arrest of the renal secretion, in spite of tin-
presence of these diuretics in the blood — the proof that the glomeruli are involved
being this, that previous section of the vaso-motor nerves of one kidney is followed
by abundant secretion of urine when the blood-pressure is raised, while the other
kidney scarcely secretes at all. It further appears from Griitzner's experiments
that digitalis and strychnia exert a peculiar influence on the renal arteriole.-, lead-
ing to vascular spasm and arrest of the urinary secretion, which does not depend
on the vaso-motor action of the medulla oblongata, since it occurs indifferently
whether the vaso-motor nerves of the kidney are divided or intact. That the
effect is due to intra-renal vascular spasm is shown by the abundant diuresis
which occurs at a later stage when the spasm has ceased, but the general arterial
pressure continues high. — Med. Times and Gaz., March 2, 1878.
Diuretic Properties of the Hydrohromate and Citrate of Caffeine.
At the meeting of the Paris Societe de Therapeutique on November 27, Pro-
fessor Gubleu spoke on the diuretic properties of hydrobromate of caffeine (Bul-
letin Ge'ne'ral de rIh€rapevtique, December 15). After having cited some test
cases, he quoted one of a man suffering from an organic disease of the heart,
whose liver was on the way to undergo the cirrhotic degeneration which precedes
what is called nutmeg-liver. As a consequence of this affection, oedema of the
lower limbs and abdomen was diagnosed. Digitalis had very little effect. M.
Gubler then gave an hypodermic injection of fifty centigrammes of hydrobromate
of caffeine. Diuresis set in after the second day, and gradually reached four
litres and a half. When the injections were discontinued, the urine diminished
gradually to a smaller quantity than the normal amount ; the oedema, which had
almost completely disappeared during the time of the diuresis, again appeared.
Making a fresh injection, M. Gubler obtained the same result. It is important to
note that with caffeine diuresis is abundant and almost instantaneous, while with
digitalis the increase of urine only comes on on the second or third day. The
caffeine, also, either citrate or hydrobromate, may be introduced under the skin
without exercising any irritant action on the subcutaneous cellular tissue. M.
Fereol mentioned the case of a patient who, suffering from a heart disease, had
reached the last stage of cachexia. M. Gubler, who was called in consultation,
prescribed an injection of morphia, and a draught with thirty centigrammes of
caffeine. The next week, the urine amounted to one litre and a half, but the
improvement did not last long, on account of the concomitant lesions of the kid-
neys. Death occurred two days afterwards. M. Gubler remarked in reference
to this case, that the diuresis was always seen to diminish gradually, on account
of the habituations of the organism to the physiological action of the drug. Account
must also be taken of the reserve of liquid to be eliminated. Thus, for instance,
digitalis has been given in cases in which there was no oedema nor infiltration
(pneumonia) ; diuresis was not then observed. In a word, the diuretic effects
are in proportion to the quantity of liquid accumulated. — London Med. Record,
Jan. 15, 1878.
Quinetum and its Therapeutical Value.
The name quinetum was given by Dr. De Try to the collective alkaloids ob-
tained from Peruvian Bark by a very simple process. Dr. H. J. Yixkhuysen,
Physician to the Household of the King of the Netherlands, states (The Prac-
titioner, Feb. 1877) that he has prescribed it in a hundred different cases, and
from his observations he draws the following conclusions : —
1 . The only malarious disease in which quinetum cannot be employed in place
1878.]
Materia Medica and Therapeutics.
529
of quinine is pernicious fever. Quinetum requires more time to act than quinine,
and as rapidity of action is absolutely necessary in this disease, quinetum cannot
be used in it as a substitute for quinine.
2. In all forms of pure malarial intermittent fever, quinetum has the same
apyretic effect as quinine, but is less powerful, and acts more slowly. It must
therefore be given in large doses and at longer intervals before the ague tit, than
quinine.
3. Quinetum does not produce the unpleasant and even dangerous symptoms-
of quinine when given during the fit. and may be taken during the fit without
causing any unpleasant feeling.
4. Quinetum never causes noises in the air.
5. Persons who are liable to suffer from the toxic effects of quinine, and who
therefore cannot take it without the greatest discomfort, can take quinetum with-
out this unpleasant effect, and yet obtain a similar therapeutical result.
6. The influence of quinetum in chronic cases is greater than that of quinine.
7. The tonic action of quinetum is similar and perhaps even greater than that
of quinine.
8. The action of quinetum in cases of masked or larval malaria, and especially
in rheumatic affections due to malarious influences, is incomparably greater than
that of quinine.
On the Therapeutic Uses of Sulphate of Copper.
In the Commentario Clinieo di Pisa for September, 1877, Drs. G. Levi and D.
Barduzzi publish experimental and clinical researches on some little known
therapeutic applications of sulphate of copper. In both man and animals the
results which they have obtained are so uniform as to merit serious consideration.
The animals on which experiments were made were horses, asses, and dogs ;
the dose at first was 15 centigrammes (2| grains),- increased to one or two gram-
mes (15 or 30 grains) on the second day, according to the tolerance of the subject ;
the result was always an increase of strength and flesh. At the necropsies, traces
of the metal were found in the blood and in the liver, especially the latter. They
also gave copper on a large scale to patients in the Pisa Hospital ; especially those
affected with skin-disease, and those in whom the processes of assimilation were
impaired, Individuals affected with erythema, ecthyma, herpes zoster, eczema,
scrofula, pellagra, and tuberculosis, were treated with sulphate of copper in doses
of 3 to 7 centigrammes (about half a grain to a grain) daily, the dose being gra-
dually increased, in order more readily to insure tolerance of the remedy. The
results corresponded with those obtained by experiments on animals. The patients
bore the medicine well ; the eruptions were favourably modified ; the nutrition
was improved ; the strength and weight increased ; the mucous membranes
assumed an improved colour ; and in some cases menstruation was re-established.
The authors observe that it clearly follows from these facts that sulphate of cop-
per, administered in a proper dose, is not -only tolerated by the stomach and in-
testines, but gives a great impulse to the activity of the nutritive processes. They
arrive at the following conclusions- —
1. Sulphate of copper, given to animals in doses gradually increased from three-
fourths of a grain to 15 grains, is easily borne ; and in general this dose, far from
producing disturbances, improves the state of nutrition.
2. Sulphate of copper powerfully modifies the nutritive functions, by virtue of
the greater activity which it induces in the internal processes of tissue-change ;
and hence it is indicated in all states of the organism in which there is deficiency
or atony of nutrition and impoverishment of the blood. In the treatment of such
530
Progress of the Medical Sciences.
[April
maladies, as well as of the functional disturbances which arise from them, notable
benefit may be derived from its use.
3. The best method of administering sulphate of copper is in pill, at the com-
mencement of or during meals. — London Med. Record, Jan. 15, 1878.
Excretion of Alcohol by the Kidneys and Lungs.
Prof. Binz, of Bonn, with the assistance of Herrn H. Henbach and A. Schmidt
(Archiv f. Exper. Pathologic, vi., 287), has lately re-examined this question,
using Geissler's vaporimeter for the detection of small quantities of alcohol in the
urine, instead of the ordinary chromic acid or iodine reaction, and the same
method for the pulmonary vapour, the latter being previously condensed by pass-
ing the breath through a series of WoliF's bottles containing cold distilled water,
or through a Liebig's condenser. With the vaporimeter as little as 0.05 per cent,
of alcohol can be detected, though certain precautions, fully described in the origi-
nal, are necessary for its accurate use. Admitting all possible errors, experiments
on the urine of six patients with various febrile affections (erysipelas, pneumonia,
phthisis, etc.) showed that during a period of eight or nine hours after a given
dose of alcohol had been taken, not more than 3.1 per cent., or at the highest
computation 6 per cent., escaped by the kidneys, while in some determinations no
alcohol at all could be discovered in the urine. With regard to the excretion by
the lungs, it was found that if from thirty to sixty cubic centimetres of pure
alcohol were drunk diluted with syrup, and the patient's breath were condensed
continuously for one or two hours, and the product examined either immediately
after the ingestion of the alcohol, or at any time within six hours, not a trace of
alcohol could be found in it. Even assuming that the alcohol ingested required
fifteen hours for the whole of it to evaporate by the lungs, the vaporimeter method
was delicate enough to detect the fraction of it which would have escaped during
the progress of the experiment. The idea that alcohol is present in the breath
after wine or spirits have been drunk depends on the odour imparted by the pres-
ence of various ethers, fusel oil, etc., and not of alcohol. A quantity of pure
diluted alcohol, equal in volume to half a bottle of champagne, may be drunk
without tainting the breath in the least ; and alcohol may be subcutaneously
injected with the same result, though it is immediately detected if a little fusel oil
is added to it first. Reasoning from analogy, Professor Binz and his assistants
regard it as improbable that the skin should eliminate alcohol, if the lungs, which
are so much better constructed for excreting it, do not do so. They conclude,
therefore, that by far the larger part of any ingested alcohol is disposed of within
the organism in the processes of tissue-change ; and, if Ave remember rightly, this
is the conclusion to which the late Dr. Anstie was also led by his own experi-
ments.— Med. Times and Gaz., Feb. 9, 1878.
MEDICINE.
Melcena Neonatorum.
In a paper read at the recent meeting of German Naturalists and Physicians m
Munich [Central- Zeitung fur Kinderheilkunde, November 15) Dr.LEDERER, of
Vienna, expressed his regret that the melasna of new-born infants was scarcely
mentioned in modern text-books on diseases of children.
He had treated eight cases, of which five were fatal from violent gastric and
1878.]
Medicine.
531
intestinal hemorrhage, together with bleeding from the umbilicus. The patients
were all boys, the youngest sixteen hours and the oldest fourteen days old ; they
were all mature and well developed ; five were strong and well nourished, while
three were tender and feeble ; four had%hemorrhage from both stomach and bowels ;
three from the bowels alone, and one from the stomaeh alone. In the cases which
recovered, the discharge was arrested within twenty-four hours, the gastric hemor-
rhage always ceasing before the intestinal. A relapse occurred in one case only
at the end of twenty-four hours. In none of the children did a disposition to
hemorrhage remain, but in nearly all there was a tendency to intestinal catarrh.
Dr. Lederer regards the etiology of melaena neonatorum as not yet settled. He
believes that the disease is not always the result of embolism, but that it depends
on various causes, as it varies from single clots in the stools to violent hemorrhage.
As a predisposing cause, he refers to the occurrence, in most of his cases, of hemor-
rhage from some organ in the father or mother. With regard to the treatment,
he directs special attention to the fact that in all his cases the children were fed
with breast-milk by the mother or nurse. In the severe cases, iced compresses
were applied to the abdomen. The internal treatment consisted in the use of
solution of sesquichloride of iron, nitrate of bismuth, and tannate of quinine. The
emaciation, anaemia, and debility were treated in all cases by suckling alone,
without any medicines. — London Med. Record, Dec. 15, 1877.
Ascites from STjphilitic Hydrozmia.
Dr. Carlo Dal Monti relates, in the Giornale Italiano delle Malattie Veneree
e della Pelle (1877) a case of ascites, the cause of which was for a long time sup-
posed to be oligajmia, since a careful examination of the viscera excluded every
other morbid process. His suspicions being excited by the appearance of a scar
over the right elbow, Dr. Dal Monti decided on giving a course of mercury.
Under this treatment there was a marked improvement in a few days, and in two
months the patient, on whom paracentesis had been performed three times, was
quite well. In confirmation of the diagnosis, the patient confessed that some
years previously he had had an infective sore on his external genital organs. —
London Med. Record, Feb. 15, 1878.
On the Use of Ozonic Ether and Lard in Scarlatina.
Dr. John Day has used, in a considerable number of scarlatinal cases, a solu-
tion of peroxide of hydrogen in ether, mixed with lard in the proportion of one
of the former to eight of the latter. He has also used, when throat affections
were at all severe, a gargle consisting of two drachms of the ethereal solution of
peroxide of hydrogen to eight ounces of water. He alleges, regarding his plan of
treatment — first, that the peroxide, being a powerful oxidizer, and therefore dis-
infectant, in a concentrated form, destroys the poison-germs before they are
thrown off from the body, so that the patient ' ' is enabled to breathe a pure atmo-
sphere, instead of, as under ordinary circumstances, an atmosphere contaminated
by the poisonous emanations from his own body;" secondly, that, in consequence
of the rapidity with which the scarlatinal poison is destroyed, desquamation of the
cuticle seldom occurs ; thirdly, that it places in the hands of the practitioner a
positive means of arresting the spreading of the disease.
The notes of fifty-five cases treated on this plan by Dr. Day between April,
1873, and April, 1875, were laid before the Council of the City of Melbourne, as
the Local Board of Health, when they were ordered to be printed, and copies
forwarded to the several Local Boards of Health in the colony. The notes show
that fifty-three of these cases recovered ; but the result was not mentioned in two
532
Progress of the Medical Sciences.
[April
cases, and we can, therefore, only speak as to fifty- three. This of itself, although
good prima facie evidence of its utility, as no other treatment was adopted, is
not sufficient, as it is well known that the disease prevails in a very mild character
for lengthened periods, and then assumes, for a longer or shorter time, a malig-
nant form. That the cases were very mild, is rendered probable by the com-
parative rarity of sore-throat. The most important part of the evidence is the
extreme rarity with which other children living in the same houses became affected
with the disease ; indeed, with the exception of two instances in which the inunc-
tion was imperfectly carried out, it was confined to the person first affected. In-
stances are mentioned of children being attacked in the one school where there
were ten boarders and twenty-five day-scholars, in another where there were six
other boarders and about sixty day-scholars, without any infection of the other
children. The exceptions almost prove as much, because in one case the inunc-
tions were continued for five days only, and four other children became infected
a few days after they were left off; and, in another, two servants had a slight
attack, and did not use the peroxide, when two children and an adult contracted
the disease.
These statements are such as to render a trial of the plan advisable, not only
for the sake of the patients, but of the public. There is no doubt that peroxide
of hydrogen is a very unstable compound, which readily parts with one atom of
its oxygen, and also liberates with some degree of violence the oxygen in the
oxides of certain metals, and thus reduces them to a metallic state. The ethereal
solution has a certain amount of stability, owing to the affinity of ether for the
peroxide ; but nevertheless we are not prepared to admit all the powers and vir-
tues claimed for it by Dr. Day. He has also, as he believes, extended its useful-
ness to the prevention of pyaemia, erysipelas, and puerperal fever, in hospital
practice, by having the walls painted and the floors coated with paraffin, and then
polished with turpentine ; thus preventing the use of soap, an alkaline compound,
for cleaning the floors and walls. — British Med. Journ., Dec. 8, 187 7.
On the Treatment of Erysipelas by Silicate of Soda.
This method has been employed specially by Dr. Alvarexga, of Lisbon, who
credits it with great efficacy. His paper (an extract of which is given in the
Journal Mid. Chirurg. de Pestli) is based on 48 cases of erysipelas of the scalp,
face, and limbs, both fixed and erratic. He asserts that, with the help of this
remedy, the disease does not last more than four or five days. The solution of
silicate of soda used is the same which is employed in the manufacture of immov-
able apparatus. It is diluted with seven or eight times its weight of distilled
water. It is very important to make a preliminary essay of this preparation with
litmus paper ; so long as it is acid, soda should be added to neutralize it. The
solution must be spread over the affected parts, morning and night, with a pencil,
and the surfaces must be allowed to dry in the air. At the end of four or five
days, when the fever, cedema, and redness, have subsided, the use of the silicate
of soda is suspended, and the parts affected are covered up with cotton-wool
steeped in oil of sweet almonds. — London Med. Record, Jan. 15, 1878.
New Symptom o f Paralysis Agitans.
M. Debove communicated to the Hospital Medical Society (Jan. 25, 1878)
a symptom of paralysis agitans which he has never seen mentioned. A patient
affected with this disease is unable to read. At first it was thought that this
resulted from the trembling of the hands, but it was found that it existed if the
book was placed on a table. The patient could read a single line ; then, after a
1878.]
Medicine.
533
rest, he commenced on the following line, but suddenly recurred to the preceding
one. M. Debove considers this ocular phenomenon analogous to the trouble in
walking, to propulsion and retropulsion, and proposes to give to it the name of
latero-pulsion. — Gaz. Hebdom., Feb. 8^ 1878.
Lesions of the Anterior Nerve-Roots in Diphtheritic Paralysis.
Dr. J. Dejerine describes {Gazette Medicate, Xo. 33, 1877) the result of
the post-mortem examination of three children who died of diphtheritic paralysis
affecting the pharynx. In one, almost all the muscles of the body had been
paralyzed ; in the other two, the muscles of the neck and inferior limbs were
affected. The anterior nerve-roots were examined, after lying for twenty-four
hours in a one-per-cent. solution of perosmic acid. In the case in which the
paralysis had been most extensive, the author found in most of the nerve-fibres
indications of advanced parenchymatous neuritis (degeneration). The axis-cylin-
ders had disappeared, the medullary substance was split up or even replaced by
drops of myelin, the nuclei of the neurilemma and of the interstitial connective
tissue had undergone proliferation. Similar changes were observed in the peri-
pheral nerves connected with the muscles ; the muscles themselves appeared to
be quite unaffected. Similar but less marked changes were found in the two
cases in which the paralysis was neither so extensive as in the first, nor had lasted
so long during life. The change in the nerves resembled that which they undergo
when deprived through any cause of the influence of their trophic centres ; and
the author thinks it probable that the change in the peripheral nerves is dependent
on an intramedullary lesion. The examination of the spinal cord is reserved for
a future occasion. — London Med. Record, Feb. 15, 1878.
Pathology of Tetanus and Hydrophobia.
Dr. Joseph Coats, at a late meeting of the Royal Medical and Chirurgical
Society (Lancet, Dec. 15, 1877), read a paper on this subject, of which the fol-
lowing is an abstract. The paper first described the lesions met with. In teta-
nus the central nervous system shows hyperemia and certain appearances in the
neighbourhood of the bloodvessels. In the cord and medulla oblongata, pons,
corpora quaclrigeniina, and corpus striatum, but chiefly in the two first named,
there is a granular material around the vessels, probably an exudation. In the
medulla oblongata it is noted that a longitudinal vessel in the posterior parts is
particularly affected, and that here, as well as in other parts, there are occasional
hemorrhages. In the convolutions there is an exudation of a yellow fluid outside
the smallest vessels, the medium-sized ones (which are those affected in the cord
and medulla oblongata) having mostly escaped. In hydrophobia there is, in the
central nervous system, an aggregation of leucocytes around the bloodvessels. In
the cord, medulla oblongata, pons, and corpora quadrigemina, it is the medium-
sized vessels which are so affected ; in the convolutions it is those of small or
capillary size. The salivary glands are infiltrated with leucocytes, which have
special relations with the bloodvessels. The mucous glands of the larynx are
similarly affected, though much less intensely. The kidneys are hypersemic, with
aggregation of white blood-corpuscles within them. The pathology of these two
diseases is then discussed, and it is pointed out that there is a great similarity in
the distribution of the lesions in the central nervous system, as well as a certain
analogy in the kind of lesion. The special distribution of the lesion is conqmred
to the localization of the tubercles in tubercular meningitis, and is ascribed to
physiological and anatomical peculiarities of the circulation, Attention is also
drawn to the fact that in hydrophobia the lesions are not confined to the central
534
Progress of the Medical Sciences.
[April
nervous system, while in tetanus facts are deficient in this regard, but a paren-
chymatous affection of the liver, kidney, etc., is asserted by one author- The
special localization of the symptoms, in both diseases, in the tongue, throat, and
neck, is associated with the special prevalence of the lesions in the medulla oblon-
gata, and especially in the neighbourhood of the nuclei of the nerves, in the floor
of the fourth ventricle, etc., it being pointed out that the principal nutrient ves-
sel of the medulla is especially related to these nuclei of gray matter. It is con-
cluded that in tetanus and hydrophobia we seem to have two different poisons,
each of which, circulating in the blood,' attacks the central nervous system. These
agents irritate the nervous system, but as they are different in nature, so the kind
of irritation they produce is different. There is, however, a remarkable similarity
in the localities indicated by them, and these seem to be specially the spinal cord,
medulla oblongata, and corpora quadrigemina ; and, to a lesser degree, the cere-
bral convolutions. The irritation seems to centre in the medulla oblongata, and
in a particular region of it, this localization being probably determined by the
anatomical and physiological relations of the nutrient vessels. The high tempe-
rature met with in hydrophobia, and sometimes in tetanus, is regarded as not
inconsistent with these views.
Carbolate of Soda in Whooping-cough.
M. Pernot {Lyon M&dicale, Sept. 23, 1877) considers that he has discovered
a specific for this troublesome affection in "ph&nate de sonde," and gives details
of cases in which, after other means had completely failed, he was able, by the
use of it, to effect a complete cure in from ten to fourteen days. He places about
40 grammes of the crude salt in a porcelain capsule, and heats it over a spirit
lamp so as to disengage carbolic vapours, the child being kept in the vapour a
short time at first, and a longer time as he becomes more accustomed to it. In
the most rebellious cases he has not required to use the treatment more than three
times a day, and in most cases it has only been necessary to use it night and
morning. He discusses the mode of preparation of carbolic acid and its salts, and
ascribes the curative properties of the phenate of soda to the tarry compounds
which it contains. " My observations," he says, "are now numerous; they, for
the most part, resemble each other, and, speaking generally, we may sum up the
results in the following words : 1st. There is a notable diminution in the number
of ' kinks' after two to ten days' treatment. 2d. The respiration is less painful,
less anxious. 3d. The ' kinks' are of shorter duration. 4th. There is less vomit-
ing, possibly because the ' kinks' are shorter. 5th. Finally, the most stubborn
cases, if I may so express myself, cease to advance from the commencement of
the treatment, then diminish in intensity, little by little, and afterwards more
rapidly." — Glasgow Med. Journal, Jan. 1878.
Treatment of Syphilitic Laryngitis.
M. H. Duret (JJ Annie Medicale, No. 10, 1877), in the course of a review
of M. Isambert's work on syphilitic laryngitis, suggests the following methods of
treatment. The general treatment should consist in protiodide of mercury in pills
(1 to \ grain three times a day), or bichloride in solution. Should the affection
have passed the secondary stage, iodide of potassium may be employed, or in
stubborn cases, the " mixed treatment." Tonics, iron, quinine, etc., are usually
called for. The patient should carefully avoid catching cold, and should avoid
the use of tobacco and alcoholic liquors. Complete repose on the part of the
organ itself is absolutely essential. The local treatment is of great importance.
In the early stages, when there is only congestion or superficial ulceration, it
1878.]
Medicine.
535
should consist of insufflations of powdered tannin, alum, nitrate of silver, or,
better still, spray of carbolic acid solution, or solutions of alum, acetic acid, sul-
phate of zinc, etc. When the laryngoscope shows ulceration, the local treatment
should be more precise and energetic. Cauterization at the seat of ulceration
may be practised, by means of a small *sponge moistened with tincture of iodine,
solution of nitrate of silver, or of sulphate of copper, 1 to 30 ; of alum, 2 to 30 ;
of sulphate of zinc, 1 to 100. These substances are preferably to be dissolved in
pure glycerine. The crayon of nitrate of silver or sulphate of copper may also be
employed. Experience has shown that excessive inflammation and oedema of the
glottis are not to be feared with this treatment. M. Isambert has obtained excellent
results in obstinate cases by the use of chromic acid (1 to 8 and 1 to 5), which
modifies the pathological tissues advantageously. When necrosis of the cartilages
sets in, a practised surgeon may sometimes succeed in preventing extension of the
injury by cauterizing the diseased points by means of the galvanic cautery. Dr.
V. ]\Jasson, in his thesis (Paris, 1875), has given the indications for tracheotomy
with great exactitude. The surgeon may be called upon to perform this opera-
tion on account of asphyxia from oedema of the glottis, gummy tumour, or vege-
tations obliterating the air-passages, abscess, inflammatory swelling, or obstruc-
tion by loosened portions of necrosed cartilage.
When asphyxia comes on progressively, Isambert recommends cauterizations
by chromic acid (1 to 3), thus crisping the swollen tissues, giving access to the
air, and sometimes influencing the disease favourably at the same time. He
reports two cases cured in this way. The patient must, however, be carefully
watched, and if relief be not gained it will be necessary to operate. When the
progress of asphyxia is sudden, tracheotomy is to be performed at once, even
when the patient is in extremis. M. Trelat reports seventy-six recoveries in one
hundred cases of tracheotomy, in oedema of the glottis from syphilitic laryngitis. —
London Med. Record, Feb. 15, 1878.
The Treatment of Asthma.
Prof. Germain See, whose recent enthusiastic praises of salicylic acid in
rheumatism and gout were received with some scepticism by the Acad emie de
Mtidecine, has just read to that learned body a paper, in which he speaks (Bul-
letin de V Academic, January 29) in scarcely less warm tones of the efficacy of
iodide of potassium and the iodide of ethyl in the treatment of asthma. After
adverting to the few occasions on which iodide of potassium has been hitherto
used, he observes that his own employment of this substance has not been for the
mere relief of the paroxysm, for which it obtained some success in the hands of
Trousseau, but as a means of effecting the cure of the disease itself, preventing
the development and return of the paroxysms which constitute the attack that
may last for a longer or shorter time. He began his investigations with it in
1869, after having convinced himself that the medicinal substances which had
hitherto proved most useful in asthma, as the bromide of potassium, and especially
chloral, only exert a very temporary and doubtful effect. Since then he has met
with fifty cases, and he has been able to keep twenty-four of these under pro-
longed observation, never for less than half a year, and in some' of the cases for
three or four years. He dissolves ten grammes of the iodide in 200 of wine or
water, and grves before each meal, twice a day, a dessertspoonful (eight or nine
grammes), so that the patient takes daily sixteen or eighteen grammes of the
solution, or one gramme eighty cent, of the iodide daily. After some clays this
quantity is gradually doubled. The same doses may in preference be taken in
syrup or orange-peel. If the patient becomes disgusted with the taste he may
take the iodide in wafers. There is no definitive time for the duration of the
536
Progress of the Medical Sciences.
[April
treatment, but generally at the end of two or three weeks, when the attacks are
attenuated or abolished, the dose may be diminished to a gramme and a half per
diem. From time to time the treatment may be interrupted for a day, but a
longer interruption may be followed by a return of the accident. In one case a
patient who had been cured for a year, having suppressed the iodide for four
days, was again attacked. Any accompanying cough may be relieved by the
addition of a little extract of opium or syrup of poppies, while, when there is not
much cough or catarrh, two or three grammes of chloral given in the evening assist
in diminishing the dyspnoea.
The effects of the iodide on the asthma and its paroxysms are — 1. The respira-
tion becomes free in about two hours ; and when it has been administered some
hours before the paroxysm the development of this is almost certainly prevented.
The second paroxysm is suppressed with certainty. 2. The respiratory murmur
can be heard in regions wherein it was suppressed. 3. Recent emphysema dis-
appears, with the exaggerated sonority dependent upon it. 4. The rales cease
to be sibilant, and become mucous, alloAving of the penetration of air. 5. At the
end of some hours the orthopnoea and emphysema have given place to normal
respiration, intermingled or not with disseminated mucous rales. G. When the
asthma is chronic with permanent emphysema, if the treatment be continued
after the subsidence of the attack, not only do the paroxysms totally cease, but
the emphysema and oppression habitual to the asthmatic entirely disappear, espe-
cially in dry asthma. In catarrhal asthma the catarrh may persist for a longer
or shorter time after the dyspnoea has disappeared. 7. When the asthma is due
to a valvular lesion of the heart, the effects produced arc but slight; but when it
is connected with degeneration or hypertrophy of the cardiac tissue itself, the
iodide treatment leads to the disappearance of the dyspnoeic element. But before
pronouncing on the existence of cardiac asthma, we should be aware of a fact that
may easily give rise to error. This is, that in a great number of the subjects of
asthma we may observe at the apex of the heart, and more rarely at the base, a
very gentle but very evident systolic bruit de souffle, which may lead to the fear
of the existence of valvular lesion. But this sound, which seems to reside in the
valves of the right side of the heart, entirely disappears, and that in some days,
with the removal of the asthma by means of the iodide treatment.
As inconveniences of a prolonged employment of the iodide, maybe mentioned
— 1. Oozing of blood from the mouth and fauces. 2. Haemoptysis. This occurs
only in those predisposed to tubercle ; and in all such subjects- and even when
the diagnosis is doubtful, the iodide must be proscribed. 3. Loss of appetite and
disgust at food. For this it suffices to suspend the treatment for a day from time
to time, and to diminish the dose during a week. 4. Emaciation. This is not
a contraindication, for at a later period the patients may recover their flesh. 5.
Iodine cachexia and diffluence of the blood have never been met with even after
prolonged treatment. The general result is, that a cure takes place in almost all
cases, even when the patients are placed amid atmospheric conditions which are
habitually injurious (thus, a bakeress, who always had paroxysms of asthma
excited by inhaling flour, was by the use of the iodide enable to continue her
occupation). The patients also resist far better the changes of temperature, the
influence of heat and cold, the action of the wind and of dusts. No precaution
has to be taken as regards hygiene and regimen, and the use of coffee and tobacco
has not seemed to be injurious.
The Iodide of Ethyl. — Prof. See has employed inhalations of this substance in
five cases of asthma, and the paroxysm was arrested in all very readily. In three
cases of cardiac dyspnoea it also acted favourably, and in two cases of chronic
bronchitis accompanied by dyspnoea the effect, although much less prompt, was
1878.]
Medicine.
537
advantageous. Quite recently, in a case of cedematous laryngitis, inhalations
repeated ten or twelve times a day effected a cure. Like the iodide of potassium,
the iodide of ethyl increases the bronchial secretion, and by this hypersecretion
renders it more fluid, and thus favours the admission of air into the pulmonary
alveoli. The iodine stimulates the action of the respiratory centre, and, by reason
of the greater quantity of blood this is brought into contact with, respiration becomes
more easy, being still further aided by the ether in combination with the iodine.
The general conclusions to be drawn from the paper are — 1. Iodide of potas-
sium constitutes the most certain means of curing asthma, whatever its origin may
be. 2. The iodide of ethyl relieves the paroxysms of asthmatic dyspnoea with
great rapidity. It also appears to act advantageously in cardiac and even in
laryngeal dyspnoea. — Med. Times and Gaz., Feb. 9, 1878.
Use o f Pure Creasote in Pulmonary Phthisis.
In the Gazette Hebdomodaire, Nos-. 31 and 33, 1877, MM. Bouchard and
Gimbert give the result of their observations on the effects of creasote in
phthisis. They used a very pure preparation, free from carbolic acid, of specific
gravity 1066, having a strong smell of tar, forming a clear solution with collodion,
soluble in diluted alcohol, and, when treated with chloride of iron, yielding a
green colour, which soon passed into brown. The following formulae are spe-
cially recommended : —
Pure creasote, 13.5 parts; tincture of gentian, 30 parts; alcohol, 250 parts ;
Malaga wine sufficient to make up a thousand parts ; of this, from two to five
tablespoonfuls are taken in water daily.
Or a mixture is made of 2 parts of pure creasote with 150 of cod-liver oil.
The daily dose of creasote varied between 40 and 60 centigrammes (6 to 9
grains ; in rare cases as much as 80 centigrammes to a gramme (12 to 15 grains)^
were used.
In this way the authors treated 93 patients in various stages of phthisis. Of
these, 25 were "apparently" cured, 29 were improved, 18 remained no better,
and 21 died. The term " apparent recovery" is applied by the authors to cases-
in which the cough and expectoration ceased, the fever disappeared, the weight'
increased, and the physical signs changed so as to indicate cicatrization. By
"improvement" they denote a condition in which the cough and expectoration)
were permanently lessened, the body-weight increased, and the physical signs
indicated an arrest, or a diminution of the process of destruction.
Of the 93 patients, 25 (27 per cent.), were apparently cured, viz., 5 in the
first and 20 in the second stage of the disease. Of the 29 (31 per cent.) patients
who were improved, 3 were in the first, 21 in the second, and 5 in the last stage.
Of the 21 (23 percent.) who died, 12 were in the second, and 9 in the third
stage. Creasote thus exercised an unmistakably favourable influence on 54 cases
out of 92. This influence consisted chiefly in diminution of the expectoration,,
cough, and fever, while the appetite, strength, and weight were increased. In
most cases the night-sweats disappeared under the use of the remedy. Some
days before the diminution of the expectoration and cough, an improvement can
be detected in the physical signs, especially those which depend on the presence
of fluid in the bronchi and in the cavities ; later, the symptoms indicating indu-
ration of the pulmonary tissue disappear or are improved. The latter action
sometimes takes place, the authors say, with almost incredible rapidity. The
authors cannot say, as they have not yet had an opportunity of making a post-
mortem examination, whether the favourable action of the remedy lies in obso-
lescence (calcification) of tubercle.
No. CL April 1878. 35
538
Progress of the Medical Sciences.
[April
The chief benefit of this treatment appears due to the limitation of the bron-
chial secretion ; and this leads in the end to diminution of the cough, which at
first generally increases under the use of creasote. If the cough remain obstinate
or become worse, the further use of the medicine must be stopped. The creasote
treatment is especially beneficial in cases attended with expectoration of purulent
or fetid matter. As regards haemoptysis, it seems that creasote does not act as a
curative, but only as a palliative, rendering the attacks of hemorrhage less fre-
quent. The reduction of the fever is to be ascribed to the improvement in the
local affections of the lung. Creasote appears to have no influence on the diar-
rhoea of phthisical patients ; on the other hand, it improves the appetite, and is
efficacious against the frequent vomiting to which the patients are subject. The
authors, in summing up, conclude that creasote is indicated in phthisis generally,
except in florid phthisis. The contraindications to its use are, intolerance on
the part of the stomach, and increase of the cough and dyspnoea in certain asthenic
forms of the disease. — London Med. Record, Feb. 15, 1878.
lite Diagnosis of Extra-Pericardial Adhesions.
Two papers have recently appeared which add a little to our knowledge on this
head, which hitherto has been scanty enough. For long it has been known that
systolic retraction of the praecordia is by no means a trustworthy sign of these
adhesions, the sign having been present when no adhesions were found after
death, and the converse has been equally common. Dr. O. von WiDMAKN,
writingin the July number of Virchow's Archie, suggests that the essential factor
for the production of systolic retraction is a change in the position of the heart,
with or without adhesions. During systole, the heart's right-to-left diameter
undergoes shortening, so that, if by any means the organ were so displaced that
its normally lateral surfaces become antero-posterior, during systole a shortening
would take place which would permit the atmospheric pressure to exert its influ-
ence on the chest wall, and cause a depression over the cardiac area. Still more
lately, Dr. Riegel, in the Berliner Klin. Wochenschrift for November 5th,
draws attention to a sign which he thinks of importance in the diagnosis of the
actual pressure of adhesions ; this is a diminution of the heart's impulse during
respiration. Normally, the heart's apex-beat is felt more forcibly and reveals
itself more decidedly on a cardiagram during respiration than inspiration; the
converse condition, which Riegel has observed in several cases of pericardial
adhesion to the border of the lung, is explained, he thinks, by the inability of the
latter organ to come forward during inspiration, while in respiration they retract
full upon the pericardium, and so impede the heart. — British Med. Journ.. Dec.
29, 1877.
On the Treatment of Serous Effusions by Limitation of Fluid in the Food.
Dr. W. B. Cheadle, Physician to the Hospital for Sick Children, reports
(Lancet, Dec. 15, 1877), the results of an investigation which he made on the
limitation of fluid as an aid to the treatment of serous effusions. His experience
has been too limited to furnish any complete and final proof of the exact value
of the treatment adopted. But one or two results come out very clearly, and are
sufficiently striking and important to merit further examination — viz. : —
1. The fact that, in cases of serous effusion at any rate, if the fluid taken into
the body as drink be limited to a small quantity, an amount of fluid can be drawn
out of the body by the stomach and bowels greatly in excess of that thus put into
it at the time.
2. That, although the excess of fluid thus drawn off may be obtained, to some
1878.]
Medicine.
539
extent, at the expense of the other secretions or the blood, the simultaneous sub-
sidence of the dropsical accumulations, and the absence of any other sufficient
source of supply, show that it must have been chiefly derived from the latter.
3. The proportion of outflow by urine to inflow by drink, or the gain in drain-
age by the kidneys, was always greater when the fluid taken in as drink was re-
duced below twenty ounces ; and more than this, that the gain in drainage was
in inverse proportion to the fluid swallowed.
4. The greatest drainage — i.e., the greatest excess of outflow over inflow — was
attained in each case under the administration of digitalis.
5. The reduction in the gross outflow of urine was always less in proportion
than the reduction of inflow by drink, with which it corresponded ; and, con-
versely, the increase of urine was always less than the corresponding increase of
inflow by drink. The latter result may, however, have been effected by the
previous privation. While it appears, therefore, that in these cases the drainage
by the kidneys was generally effective in inverse proportion to the quantity of
drink swallowed, and that under the influence of digitalis a greater excess of out-
flow by urine over inflow by drink was obtained when the latter was limited to
from five to sixteen ounces than when twenty to thirty ounces were taken, it does
not necessarily follow that the same rule would hold good if larger quantities of
fluid still were taken. It is possible that the additional quantity taken in may
be more than compensated by increased outflow under the action of purgatives
and diuretics. The enormous discharge of urine in the first case under the influ-
ence of digitalis, for two days before the drink was limited, would at first sight
seem to support this view. But although, owing to the amount of drink not
being measured, the means of accurate comparison are wanting, if we take the
lowest average of 30 oz. = 849 cc. as the quantity of drink, it will be seen that
the excess of inflow over outflow was 451 cc. and 195 cc, or an average of 1100
cc., as compared with 2157 and 1357, or an average of 1757 cc. for the two days
next following, when the fluid was limited to sixteen ounces. The presumption
furnished by the evidence in these cases, and especially by the record of the last,
during the period when drink was unlimited, is against the vieAv that the diuresis
would be increased in proportion to the increased supply of fluid — that is, " water
is the best diuretic." But experiments as to the effect of diuretics, and espe-
cially of digitalis, together with a free and large supply of drink, are necessary to
clear up the point satisfactorily.
It is remarkable that the sufferino- from thirst should have been so slight. The
restriction to drink caused no serious distress in any case, and the discomfort ex-
perienced was relieved and fully compensated for by a few acid drops, except in
the fourth and fifth cases, in one of which there was advanced renal disease, and
in the other much fever.
It is further worthy of note that the limitation of drink did not produce any
great diminution of the gross quantity of urine in the case of renal disease, nor
any symptoms which would forbid the adoption of such treatment on occasion in
similar cases. It would be desirable to ascertain the effect of the restriction on
the excretion of urea.
Finally, then, limitation of drink may fairly be used as an adjunct to treatment
in cases of passive dropsy, or inflammatory effusion when the acute stage is over.
In acute cases, accompanied by much thirst and fever, such restriction would
probably be ill borne. In serious renal disease I should hesitate to adopt it, ex-
cept with much caution and constant estimation of its effect upon the gross excre-
tion of urea.
540
Progress of the Medical Sciences.
[April
On Visceral Syphilis.
In the Bulletin de V Academic de M6decine, No. 43, October, 187 7, is a report
of a communication made to the Academy by M. Lancekeai x, entitled " Note
of a Case of Pulmonary Syphilis, with remarks upon visceral syphilis, and the
errors of which it is the object." M. Lancereaux writes : —
Forty years ago no one believed in visceral syphilis. Studied with timidity at
first, then with more confidence, it has gained, little by little, till, at the present
day, some physicians seem to think it amongst the most frequent of morbid con-
ditions. Post hoc, ergo propter hoc would seem to be the motto of many ; but
this is far from scientific, and many disorders are now attributed to syphilis which
do not belong to it, just as new medicaments are vaunted above measure, and
applied to all cases alike, only to return directly to the obscurity whence they
emerged. So the knowledge which has been gained of visceral syphilis is in
danger of falling into discredit. This is a serious thing, for if ignorance is cala-
mitous, the loss of acquired facts is still more so.
The recognition of the manifestations of tertiary syphilis ought ndt to rest upon
any simple coincidence of conditions, but upon special, and, so to speak, funda-
mental characters. These are furnished by the lesions, which are the indelible
signs of the malady. Armed with this criterion, the physician follows a road in
which there is no risk of wandering. Such is at least my conviction after long
and patient research, not only into the pathology of syphilis, but also into most of
the chief pathological processes.
First of all, then, taking a simple case, I shall endeavour to prove, by the com-
parison of this with other facts, that syphilis, even when hidden in the depths of
the organism, can be as surely tracked out by clinical analysis as a body forming-
part of some mixture can be isolated by chemical analysis.
A man aged 58, an hospital attendant in the employ of the " Assistance Pub-
lique," had, with the exception of pains in the head, been in good health till
November, 1S7G, when he was seized with dizziness, vomiting, and uncontrollable
hiccough. To these symptoms and violent headache, a slight degree of muscular
paralysis on the right side was soon added. He denied all history of venereal
disease ; but, as he was known to be a drunkard, and yet denied this, his repu-
diation of venereal disease was not to be depended upon. Under the influence of
iodide of potassium and a seton at the back of the neck, he improved much ; and
there only remained slight weakness of the right arm and leg, and a slight devi-
ation of the mouth. He went on well for four or five months, and then again*
suffered from vomiting and hiccough for some days. Then vision became indistinct
in the right eye ; he had a little cough and shortness of breath on exertion. He
kept up his nutrition notwithstanding. The sight of the right eye became en-
tirely lost, and then that of the left eye became affected ; he had difficult}" in
walking, and ultimately was seized with a quiet delirium, soon accompanied by
the loss of his intellectual faculties, and a semi-comatose state. The pupils
were unequal. He became violently delirious, and then died.
Necropsy. — The skin was free from cicatrices ; the skull thick and sclerosed ;
the dura mater was intact, but the other membranes, normal at the base, were
slightly thick, and white at the convexity of the cerebral hemispheres. The Pac-
chionian corpuscles were thick, and hypertrophied. Placed upon its base, the
brain divided into two halves, and allowed one to see between the lateral ventricles
a yellow membranous mass, from three to five centimetres in extent, which oc-
cupied the place of the septum lucidum, now no longer in existence. The optic
chiasmawas injected, softened, and inflamed, as well as the tissue of the nerves at
their origin. The optic papilla? were oedematous and injected. The rest of the brain
1878.]
Medicine.
541
was healthy. The lungs were closely adherent in their lower third, both to the
thoracic wall and to the diaphragm ; and they were cleft with deep fissures, like
the syphilitic cicatrices found in the liver, and, like these, also filled by newly
formed fibrous tissue. Between these cliffs the parenchyma was, in some parts,
indurated, in others, emphysematous.' The visceral pleura was elsewhere thick-
ened. The disease was symmetrical, but a little more advanced on the right side
than the left. The substance of both lungs presented similar lesions — viz., in-
creased toughness of the lower lobes, well-defined gummata. of the size of hazel-
nuts, surrounded by a zone of grayish fibroid tissue, and tracts of whitish cr
blackish fibrous tissue, which, for the most part, radiated from a common centre.
The bronchial tubes were dilated, and the glands voluminous and firm.
The other viscera showed nothing abnormal, save that the heart was fatty, and
one kidney had a deep depression on its surface. The testes were fibrous, and
the tunica? vaginales adherent.
A microscopical examination of the lungs showed that the whitish fibrous tracts
were composed of a fibrillated connective tissue, like cicatrices. The gummata
presented two distinct parts — the one central, unaffected by staining fluids, com-
posed of degenerate elements'grouped round bloodvessels, the walls of which
were notably thickened, and the channels almost completely obstructed ; the other
peripheral, staining deeply, composed of small round cells, like embryonic con-
nective tissue, some fusiform cells, and vessels with flattened epithelioid lining,
thickened walls, but still patent lumen.
This examination seems to show that gummata commences as a periarteritis,
which extends in successive circular layers, till at last the internal tunic is invaded,
the canal obstructed, and the central part degenerates. At the same time, the
neighbouring lung-tissue becomes compressed. Notwithstanding the want of
evidence of syphilitic antecedents, M. Lancereaux considers that either the testes
or the lungs in this case would supply indisputable and conclusive evidence of the
existence of syphilis. The points on which stress are laid are, that syphilis pro-
duces material lesions, which are neither diffuse nor extensive, but always cir-
cumscribed and limited ; and that its mode of development is quite peculiar.
Thus insanity, general paralysis, progressive locomotor ataxy, and pulmonary
phthisis — all of them maladies characterized by the very opposite of these features
— are absolutely independent of syphilis. With a syphilitic patient, attacked with
functional disorders of some important viscus, the brain, for example, the diag-
nosis will rest upon the following points : Is there in the case a material lesion ?
If not, syphilis is not its cause. If there be, then is the lesion diffused or circum-
scribed ? and in the last case only can the possibility of syphilis be admitted. —
London Med. Record, Dec. 15, 187 7.
On Syphilitic Disease of the Kidneys and Heart.
Dr. Axel Key relates in the Hygiea, 1877 (abstract in NordisTct Medicin.
Artiv, Band ix. Heft 3), two cases of syphiloma of the kidneys, and one of
syphilitic disease of the kidneys and heart.
The subject of the first case was a prostitute, who died suddenly. At the ne-
cropsy, besides other characteristic specific changes, one-half of each kidney was
found to be the seat of between twenty and thirty grayish- white or reddish-gray
round masses of various sizes, some isolated, some becoming confluent. They
were surrounded by a gelatinous gray- white zone, and sharply defined from the
surrounding renal tissue, so far as could be seen with the naked eye. The con-
dition could not be judged with certainty, as cadaveric changes had already com-
menced. Most of the larger masses had undergone caseous degeneration in the
centre. Microscopic examination showed the changes usual in syphiloma, espe-
542
Progress of the Medical Sciences.
[April
cially syphiloma of the liver, which the masses found in the kidney also resem-
bled microscopically.
In the second case, that of a man aged 31, the syphilitic deposits were very
numerous, and were principally found in the pyramids of the kidneys. (In the
former case the new growths were partly within and partly without the cortex
and pyramids.) They were softer than in the other case, and were in general in
a state of softening, having a jelly-like consistence. In addition to the syphiloma,
the renal tissue was the seat of induration and atrophy.
In connection with these cases, Dr. Key describes the condition of the heart
and kidneys as found by Professor Bruzelius at the necropsy of a sailor who had
died suddenly. The lower part of each kidney was found to be completely atro-
phied ; and to be sharply marked off from the upper part, which mieroscopically
appeared to be unaffected. This atrophy is characteristic of syphilis. The mus-
cular tissue of the heart also contained many connective tissue-growths, in which
were found small grayish- white or gray-yellow syphilitic deposits. — London Med.
Record j Dec. 15, 187 7.
Milk-diet in the Treatment of NepJiritis.
Dr. H. Mackiewicz sIioavs in the These de Paris (June 1877), by cases re-
ported from Dr. Lancereanx's wards, the good effects obtained by milk-diet in
Bright's disease, and how this regimen should be initiated. Asses' milk should
be used in preference ; where that cannot be obtained, cows' milk, after it has
stood for twelve hours and been carefully skimmed. It may be drunk either hot,
cold, or lukewarm, as the patient likes. On the first day of the milk regimen,
two litres (about 3j pints), with some food, should be given. The milk should
be drunk by the glass, and in small mouthfuls. The whole quantity must be di-
vided into four parts, each taken at different times at equal intervals throughout
the day. The next day three litres must be given, and no other food ; and on the
following days the quantity must be augmented by one litre, until from four to six
litres have been disposed of, according to the tolerance of the patient. If milk
have not been tolerated, Vichy water, lime-water, calcined magnesia, or some
alcoholic or acid liquid may be added to it. From one to two and a half drachms
of chloride of sodium may also be added to it with advantage. If the patient be
anaemic, some of the preparations of iron and quinine may be safely employed,
If at the end of a week the dropsy be not diminished, and the flow of urine in-
creased, the milk-diet must be given up, and recourse had to other means, such
as purgatives and sudorifices ; diuretics have no effect. This ineffieacy is always
a guide as to the gravity of the affection and its incurability. The treatment
should be continued so long as it is tolerated, until the dropsy, and, if possible,
the albuminuria have disappeared. The disappearance of the latter sometimes
only occurs five or six months after the most rigid observance of the milk-diet.
When the albuminuria has disappeared, a mixed diet should be gradually adopted,
until no more milk is given. The reappearance of the albuminuria or the dropsy,
where the albuminuria has not been improved, will always be an indication to
resume the absolute milk-regimen, which must also be resumed on the appearance of
uraemic accidents. Finally, it must be remembered that, as the milk-diet is nearly
always successful where all medication has failed, it is a duty, when any kind of
nephritis is met with, to begin by a rigid milk-diet, and only to have recourse to other
therapeutic means when success is not attained by the one under consideration. —
London Med. Record, Jan. 15, 1878.
1878.]
Medicine.
543
Cerebral Commotion as a Cause of Transient Glycosuria.
At the meeting of the Societe de Biologie in Paris on December 1, 1877, M.
Albert Robin, in support of the new theory advocated by M. Duret on cere-
bral commotion as a cause of passing glycosuria, reported a typical case. A
young man, aged 19, having fallen from the seat of a carriage, was taken to the
Beaujon Hospital. There were ecchymoses of the head, and he remained un-
conscious for many hours. As there was retention of urine, M. Robin performed
catheterization, and found that there was a notable quantity of sugar in the urine.
A short time afterwards a second examination gave no traces of sugar. This is
therefore a perfectly authentic case of temporary glycosuria, consecutive on cere-
bral commotion. M. Claude Bernard observed that this could be produced expe-
rimentally in animals. — London Med. Record, Feb. 15, 1878.
Lesion of the Pancreas in Certain Forms of Diabetes.
At a recent meeting of the Paris Academy of Medicine, M. Lancereaux
showed some pathological specimens of lesion of the pancreas in patients who had
died of diabetes, and gave the history of the cases. He said that the cases and
the specimens showed that diabetes mellitus is, at least in some cases, accom-
panied by a serious change in the pancreas. A similar change has been met
with in many other cases of diabetes ; and in these cases, as in those noted by
M. Lancereaux, the disease, of which the course has been comparatively rapid,
has shown itself by excessive appetite and thirst, great emaciation, profuse gly-
cosuria— in a word, by all the characteristics of diuretic wasting. On the other
hand, animals, the pancreas of which is extirpated or destroyed, become voracious,
are rapidly emaciated, and succumb very quickly. Taking, therefore, into con-
sideration the special characters of diabetes in cases of disease of the pancreas,
and the phenomena in animals following the destruction of this organ, M. Lance-
reaux thinks it may fairly be concluded that there exists a causal relation between
serious changes in the pancreas and the diabetes mellitus in question. This form
of diabetes is distinguished by the comparatively sudden appearance of emaci-
ation, with polydipsia and excessive appetite, and peculiar characteristics of the
alvine excreta. The prognosis of this form of diabetes is very unfavourable. The
indications of treatment consist in prohibiting the use of articles of food which
are digested by the pancreatic juice, and nourishing the patient with the class of
food which is digested in the stomach. — British Med. Journal, Jan. 5, 1878,
from La France Medicale, Nov. 17.
Use of Nitric Acid in Diabetes Lnsipidus.
Mr. Henry Kennedy recommends {Practitioner, Feb. 1878) the use of
nitric acid in the treatment of diabetes insipidus. He records five cases cured by
it, in two of them one drachm of the dilute acid was administered in a quart of
water daily, and in the remaining three the doses respectively were two, four, and
five drachms in the day, with successful result.
Symptoms and Treatment of Psoriasis Universalis.
Kaposi remarks {Wiener Medizin. Wochenschrift, Nos. 44 and 45, 1877)
that the constitutional disturbance present in some cases of universal psoriasis may
threaten life ; and that patients cured of this aggravated form of the disease may
in subsequent attacks have only the more usual localized psoriasis.
The three methods employed by Hebra in universal psoriasis to soften the epi-
dermic incrustations, namely, the application of cod-liver oil, the continual bath,
5U
Progress of the Medical Sciences.
[April
and the enveloping the body in impermeable materials, as India-rubber clothing,
although very beneficial in most instances yet in exceptional cases act injuriously
and even dangerously. Cod-liver oil may provoke eczema, in which case it must
be discontinued at once, and dusting powder freely used. In one case it provoked
a universal eruption of pustules and boils. Three days' use of the continual bath
having failed to alleviate this condition, the application of diachylon ointment to
the "whole body was employed successfully. In another case in which cod-liver
oil had produced very threatening symptoms by detaching the epidermis, the
patient's life was only saved by his being immersed in water for fourteen days.
When oils, fats, and water have failed, a cure has been effected by diachylon
ointment and bandaging. Under the use of an India-rubber suit, in some cases
very harmless and useful, the skin of the whole body may become swollen and
congested to such a degree as to imperatively demand a cessation of the treat-
ment.— London Med. Record, Jan. 15, 1878.
SURGERY.
Parenchymatous Injections of Acetic Acid in Carcinoma.
Dr. Th. Gies relates {Deutsche Zeitschrift fiir Chirurgie, Band vii., and
Wiener Medizin. Wochenschrift. Xo. 41, 1877) the case of a man aged 02. who
had a glandular swelling under the horizontal ramus of the lower jaw. As a
small nodule in the lower lip had been removed some years previously, the swell-
ing was supposed to be carcinomatous ; and this diagnosis was confirmed by
microscopic examination after its extirpation.
Soon afterwards the patient felt a pairi in the tongue, which was found to be
due to a cancerous ulcer in the left half of the organ, near the epiglottis. This
diseased portion was excised after ligature of the lingual artery and division of
the lower jaw ; and no return of the disease in the part took place during eighteen
months.
Seven months after the last operation, two new tumours appeared; a smaller
one near the left border on the lower jaw, and a larger one lower down on the
neck. The latter disappeared under treatment with ice ; the former remained
stationary. A year after the tongue had been extirpated, a rapidly growing
tumour appeared in the neighbourhood of therig-ht submaxillary g'land ; it resisted
treatment by ice, and soon pushed the trachea aside. Examination of a small
piece of the tumour, removed by the harpoon, proved it to be carcinomatous.
The author then injected into the tumour, once every week, the contents of a
Pravaz's syringe filled with a solution of one part of glacial acetic acid in three
parts of wrater. On the first day, a solution of 1 part in 9 was used. On each
occasion, the point of the syringe was moved about in the growth, so as to dis-
tribute the contents. Warm poultices were applied. Great swelling followed.
On the tenth day he made a deep incision with a pointed knife, and inserted a
drainage-tube, through which offensive ichorous matter escaped. After seventeen
days this discharge ceased, and at the end of four months only a hard nodule as
large as a hazel-nut could be felt, lying deeply in the tissue. Soon afterwards
four injections were made into the tumour near the margin of the lower jaw, and
into one which recently appeared in the left cheek, with a similar result. A new
swelling now appeared below the left ear: it increased to the size of a hen's egg,
was very hard, and microscopic examination shoAved it to have a more abundant
1878.]
Surgery.
515
framework of connective tissue than the former tumours. Injections were again
resorted to, but, considering the greater resistance of this growth, the author in-
jected two or three syringefuls daily. During eleven days, twenty-five syringes
filled with the solution of acetic acid (1 to 3) were injected. The injections in
the soft growths were almost painless, while the injections into this tumour pro-
duced great pain. On the twelfth day an incision was made. The suppuration
lasted three weeks, at the end of which time the tumour had almost disappeared.
A similar result was obtained by the author in the case of a woman who had a
soft cancerous tumour in the breast. During ten days a syringeful was injected
daily, and on the eleventh day an incision was made. After fifteen days the
ichorous suppuration had ceased, and at the end of four weeks only a small pain-
less tumour about the size of a hazel-nut remained in the depth of her breast.
In both these cases, the author made the injections for the purpose of producing
suppuration. For that reason, he used concentrated solutions of acetic acid.
He recommends attention to this method, because it may be very useful in
cases not amenable to operation, as a means of restraining the rapid growth of the
neoplasm, and possibly of producing radical cure. The cases, however, are of too
recent a date to enable a definite opinion to be formed. — Lond. Med. Record,
Feb. 15, 1878.
Arnica as a Remedy for Boils.
In the Journal de Therapeutique for Jan. 25. 1878, Dr. Planat writes that
he has found arnica possessed of rapid and constant efficacy in cases of boils. He
was led to try arnica in these cases from the result of physiological experiments
made by him, with the view of studying the mod us operandi of this substance on
wounds. Its property of producing resolution, evidently due to its influence on
the vaso-constrictor nerves, gave him the idea of applying it in all cases of acute
superficial inflammation, such as boils, angina, erysipelas, etc. These experi-
ments have convinced M. Planat that arnica arrests all furuncular eruptions with
remarkable rapidity. M. Planat makes an exception in the cases of diabetic boils,
which have not come under his observation, and of carbuncle, which, by reason of
its exceptionally serious character, he has treated in the ordinary way. He has
been equally successful in cases of erysipelas and acute simple angina, but is not
quite so clear about this as of the case of boils. The arnica was applied directly
to the inflamed parts in the form of an ointment, composed of 10 grammes of ex-
tract of fresh arnica flowers to 20 grammes of honey. If this mixture be too thin,
lycopodium or althea powder, or any similar substance, may be added so as to
give it the necessary consistence. It is spread on diachylon plaster or oiled silk,
and applied to the boil. Generally it is sufficient to renew this dressing once in
twenty-four hours. Two cm* three applications generally cause the boil to die
away at all stages of its evolution.
Dr. Planat has also given internally in cases of this character tincture of arnica
in doses of from 25 to 30 drops in a draught to be taken in teaspoonfuls every two
hours, and has thereby obtained so rapid an extinction of the furuncular eruption
that it seemed impossible to him to deny the special action of the drug. He,
however, noted greater efficiency from its direct application. — Lond. Med. Record,
Feb. 15, 1878.
Foreign Bodies in the Gisophagus.
The following is the substance of a paper read by Prof. B. vox Langenbeck
to the Berlin Medical Society on " Foreign Bodies in the (Esophagus and CEso-
phagotomy ." After indicating the usual places where foreign bodies are detained
in the oesophagus, the Professor went on to say (Berliner Klin. Wock., Dec. 17
546
Progress of the Medical Sciences.
[April
and 24) that he had met with three cases in which voluminous bodies detained
in the pharynx by compressing the epiglottis against the rima glottidis threatened
to produce immediate suffocation. The first of these was produced in the lec-
turer's presence, by a boy playing with another at catching a small apple thrown
into his mouth. After succeeding several times, he suddenly fell on the floor
with widely-opened mouth and a blue-coloured face. Fortunately, it was found
that the apple could be extracted by introducing the forefinger beside it. The
second case occurred in the person of a very robust gentleman, who came to con-
sult the lecturer concerning a hernia. Lying down on the sofa in order that it
might be examined, he suddenly became lifeless and blue in the face. On the
forefinger being introduced, a complete set of false teeth was withdrawn, the pulse
and respiration, however, not returning until some seconds afterwards. Dieffen-
bach relates an entirely similar case. In the third instance, a lady, about to
undergo amputation of the breast, exhibited at the very commencement of the
administration of chloroform labourious stertorous breathing and a dark-blue colour
of the face. The finger, introduced to draw the tongue forwards, detected and
withdrew a set of false teeth. In other cases of this kind the patients do not
always escape so easily; and it is very desirable that dentists should caution those
to whom they supply teeth in order to prevent these accidents. Surgeons, too,
before administering chloroform to elderly people, should ascertain with certainty
the existence of false teeth, and insist upon their removal. In the removal of
large foreign bodies the finger is the instrument to be resorted to before all
others ; and if they are too firmly fixed to be removed by it, then forceps or
levers should be used. Tracheotomy is always too late in such cases. When,
also, small-pointed foreign bodies — as needles, fish-bones, etc. — are detained in
the pharynx, and especially in the sacculi formed by the ligamenta glosso-epiglot-
tica, the finger should never be omitted to be introduced, in the hope of bringing
the body into the mouth, or at all events to ascertain its exact position before
employing the forceps.
When a foreign body of some size, as a large piece of meat, hard dumpling,
potato, etc., passes through the pharynx, it not unfrequently becomes detained in
the oesophagus opposite the cricoid cai-tilage, and by pressure on the larynx or
trachea causes great difficulty of respiration. Its position is easily ascertained by
the projection it causes on the left side of the throat, but its removal is often
very troublesome owing to the spasmodic contraction of the oesophagus which
takes place above and below the foreign body. Forcibly thrusting it down can-
not be too strongly deprecated, as injury to the oesophagus cannot be avoided
with certainty. A peasant applied to the lecturer for relief, having thirty hours
before attempted to SAvallow a huge piece of sinewy meat, which, being retained,
almost induced suffocation. Repeated attempts were made to remove the foreign
body by means of a slightly curved, strong forceps, but it proved immovable, only
some of the fleshy fibres coming away. (Esophagotomy was contemplated, as
during the attempts at removal the difficulty of respiration was so greatly in-
creased; but the projecting tumour having been seized by the fingers in the
neck, raised from the larynx and compressed for some minutes, the respiration
became much more free. The foreign body, although not moving from the spot,
had assumed, through this manipulation, a more elongated form, and was removed
by means of the forceps with some exertion of force. Another man applied on
account of the obstruction to respiration and swallowing caused by a pretty large
piece of tough meat which had for twenty-four hours obstructed the same part of
the oesophagus. Violent retching, caused by tickling the fauces and attempts
with the forceps to withdraw or thrust it down, failed to dislodge the body, which
was placed as in a diverticulum of the left side of the oesophagus. The tumour
1878.]
Surgery.
547
which it formed in the neck was then seized with the finders and squeezed so
powerfully that the body slid down into the stomach. Dupuytren dealt with a
potato in the same way, which had resisted all attempts to withdraw it or force it
into the stomach. When the position of the foreign body is not indicated by its
projection in the neck, we must bear in mind that the indications furnished by
the patients themselves are very deceptive. Oftentimes they are unable to de-
note its locality, and sometimes assign one that is far distant from the real one.
Thus, a woman in whom a set of teeth was lodged opposite the cricoid indicated
the cardia, and a man referred the obstruction caused by a piece of bone to the
cervical portion of the oesophagus, when it really existed in the thoracic portion.
Catheterism of the oesophagus may therefore be required to ascertain the situation
of the body. The general and almost traditional practice of employing the pro-
bang, either for the withdrawal or for the thrusting down of the foreign body,
cannot be too earnestly deprecated. A more irrational practice can scarcely be
imagined, and no other instrument has done so much mischief in proportion to
the number of cases in which it has been employed. By it we are able to ascer-
tain neither the situation nor the condition of the foreign body ; and, in place of
its withdrawal or propulsion, it sometimes becomes only forced deeper into the
oesophagus, and may even (as in two cases which the lecturer has met with) be
thrust through the wall of the oesophagus into the mediastinum. When soft
bodies obstruct the oesophagus, the forcing of which into the stomach is desirable,
the probang may be used ; but in all cases when the condition and position of
these are unknown, or their extraction seems possible, catheterism must be first
performed. For this purpose Prof, von Langenbeck uses a whalebone staff, to
the lower end of which is attached a smooth polished iron ball. This, when well
oiled, slides readily down the oesophagus by its own weight, is easily movable to and
fro, and enables us to detect with certainty hard bodies, such as coins, needles,
and pieces of bone. If the object is to force into the stomach a harmless sub-
stance, the nature of which is known, he employs an elastic oesophageal sound ;
this acts upon the foreign body as efficaciously as the probang, but slides down
the oesophagus far more easily, and renders injury much less possible. Foreign
bodies which may wound the oesophagus, or become dangerous in the intestinal
canal — such as bone, fragments of glass, coins, needles, etc., should, in Prof, von
Langenbeck's opinion, be always extracted, their extraction being a far more
certain and less dangerous procedure than forcing them into the stomach. In a
great number of such operations he has never met with any accident. The instru-
ment which he exclusively employs for this purpose is Yon Graefe's coin-extractor.
This passes with facility, and without any injury, into the oesophagus beside the
foreign body, and during its withdrawal seizes it with a certainty that leaves
nothing to be desired. Prior to its introduction, some oil should be injected into
the oesophagus, and then the end of the instrument should be guided by the left
forefinger over the root of the tongue and epiglottis against the back of the
pharynx, and thence into the tube. On withdrawing it very carefully, if the
least resistance is encountered we must desist, and move it gently to and fro in
order to disengage it from any possible entanglement in the mucous membrane.
When the instrument with the foreign body has arrived opposite the cricoid car-
tilage, difficulty in completing the extraction is caused by the cartilage springing
backwards ; but this may be obviated by pressing the end of the instrument,
which has now become visible, against the posterior wall of the pharynx. When
the isthmus of the fauces has been reached, we should always, and especially with
restless children, have the left forefinger in readiness, in order to seize hold of
the foreign body, which might otherwise escape. A pair of firmly grasping pha-
ryngeal forceps, and this coin-extractor, constitute all the apparatus required.
548
Progress of the Medical Sciences.
[April
There is, however, one inconvenience attending the coin-extractor that must be
noticed, viz., when the foreign body becomes so firmly wedged into the extractor
that this cannot be loosened from it and withdrawn. Prof. Adelmann relates a
case in which the extractor, thus embracing the foreign body, could not be re-
moved during two days. In the case of a girl who had swallowed a shawl-pin,
which occurred to the lecturer, its position at the lower end of the oesophagus
having been detected by means of the sound armed with the iron knob, it was
seized by the coin-extractor. So firmly, however, had it penetrated the oesopha-
gus that it could not be withdrawn ; and, after repeated efforts, when the attempt
was abandoned, the instrument could not be separated from the pin until after
half an hour, when the pin slipped into the stomach. Bloody stools followed,
and the patient complained of great pain in the stomach for a month after the
accident, but the pin has never been found.
Casting one's eye over the statistics, it would be concluded that the passage of
foreign bodies into the oesophagus is a very dangerous occurrence; for of the 314
cases collected by Adelmann,1 109 proved fatal. But the proportion of fatal
cases is far less than this, for the great majority of cases, when the foreign body
is easily extracted or passes into the stomach, are never published at all. In Prof.
Langenbeck's thirty-four years' practice he Las had a very great number of these
cases, and has never met with a fatal occurrence. Pieces of money can always
be removed, and some of the pieces of bone slip into the stomach as soon as they
have been dislodged by the extractor ; but the great majority of flat and pointed
pieces of bone are removed. In the two fatal cases of perforation of the oesopha-
gus related by Prof. Busch, the sponge-probang had been employed, and the
foreign body could not be detected. However, from this statistic the conclusion
is to be drawn that if the foreign bodies be not promptly removed, and if unsuit-
able and violent manipulations are employed, they may seriously endanger life.
Above all things, it is important that the body be removed as soon as possible,
and that the practitioner at once proceeds with decision.
When the removal cannot be accomplished, and the nature of the body does
not admit of its being thrust into the stomach, when the cervical oesophagus is the
part of the tube concerned, we should perform oesophagotoniy. It is a compara-
tively rare operation, for, according to Konig, from the time of its first perform-
ance by Goursault in 1738 to 1872, it has only been executed twenty-six times for
the removal of foreign bodies. Its indication has been generally believed only
rarely to occur, while its danger and difficulty have been exaggerated; and an
examination of recorded cases of foreign bodies in the oesophagus shows that it
should have been performed much more frequently, and that, without doubt,
many lives might have been saved by it. The twenty-six operations referred to
by Konig, and two now related by the lecturer, were followed by twenty-three
recoveries and five deaths, some of the latter being due to the too prolonged resi-
dence of the body ; so that the operation must be regarded as one attended with
very little danger. Almost all living surgeons agree that the mode of making
the incisions recommended by Guattani is the best, the skin on the left side of the
neck being divided from the middle of the thyroid cartilage to the anterior edge
of the sterno-cleido-mastoid, and to about five centimetres above the manubrium
sterni. After the superfacial fascia has been divided, the sterno-cleido is drawn
outwards and backwards by means of double hooks, and the common carotid then
becomes visible through the middle cervical fascia. The fascia is to be divided
in the direction of the long axis of the wound, and drawn outwards and backwards
by means of strong hooks, the carotid being kept out of the operation-field. It
1 Prager Vierteljalirsscrift fiir die Practische Heilkunde, Bd. IV., 1847.
1878.]
Surgery.
549
must not be forgotten that this artery lies more superficially than the oesophagus,
and that the latter only becomes visible after the deep cervical fascia has been
divided. This is done at the outer edge of the sterno- thyroid muscle, after having
drawn the larynx by means of a hook Jo the right side. The muscle being now
drawn towards the median line, the oesophagus becomes visible. Before opening
it an oesophageal sound, made of gum-elastic or pliable metal, should be intro-
duced for the purpose of projecting the oesophagus more to the left, and rendering
its opening more easy and certain. The separation of the fascia in order to
expose the oesophagus is best accomplished by raising it by means of two hook-
forceps and dividing it between them, allowing the knife to act more by its pres-
sure, thus avoiding injury to the inferior thyroid artery and inferior laryngeal
nerve. Injury to the recurrent nerve is not much to be feared, as this passes
upwards between the trachea and oesophagus, and is with the former organ drawn
towards the right ; it is only in question when a foreign body of large circum-
ference thrusts the oesophagus far towards the left. The nearer an operation
approaches important organs, the more must it assume the character of a delicate
anatomical dissection; and in order to avoid injuring important vessels, it is
highly desirable to separate the tissues as much as possible by means of the fingers
or blunt instruments. When the foreign body does not project the oesophagus,
and cannot be felt externally, the passage of an oesophageal sound by the mouth
very much facilitates the operation. One circumstance may render access to the
oesophagus exceedingly difficult, and is of the more importance, inasmuch as it is
not noticed in any of the descriptions of the operation. This is the tumefaction
of the thyroid gland. If a large foreign body be detained for several days oppo-
site the cricoid cartilage, causing difficulty of respiration by pressure on the
larynx, swelling of the thyroid due to a stasis of the blood in the veins is always
present. The tumefied gland lies so much over the oesophagus that this may be
entirely covered by it; and in order that the gland may be raised from the
oesophagus its enveloping fascia must be divided.
Prof. v. Langenbeek terminates his communication by the narration of two
cases in which he performed oesophagotomy with success for the removal of false
teeth. — Med. Times and Gaz., Jan. 26, 1878.
Foreign Body in the Oesophagus, with Perforation of the Aorta.
Dr. Aschenborn relates the following case in the Berliner Klinische Wochen-
schrift, for December 10th. V., a joiner's apprentice, was admitted to the
Bethany Hospital on July 1, 1876. That morning he felt severe pains during
respiration, but had two clays before begun to suffer from pains in the epigastric
region and along the gullet after swallowing a hard morsel of bread. On admis-
sion, there were accelerated costal and shallow respiration, a full pulse of 100, a
temperature of 39° C. (102.2° F.). The heart and lungs were normal. There
was acute sensibility to pressure at the pit of the stomach and about the insertion
of the diaphragm, but no difficulty of swallowing. During the next six clays the
pulse rose at times to 120, with febrile symptoms, and deglutition became ex-
tremely painful, except in the case of fluids. The respirations rose to 40 per
minute, and w^ere "throughout costal and shallow, the area of cardiac dulness was
extended. The neck swelled in the supraclavicular spaces, especially on the
right side. On the 5th a longitudinal incision was made in the posterior wall of
the pharynx, yielding an offensive sanious fluid of a dark colour, but no pus.
After this, his general condition improved somewhat, but the swelling of the neck
was not diminished. On the 7th, in the forenoon, two bloody stools were sud-
denly passed, his strength and general condition remaining unchanged for that
550 Progress of the Medical Sciences. [April
and the following day. During the night of the 8th-9th of July a copious stool
of pure blood was passed, followed quickly by collapse. Under the use of port
wine and camphor, the patient rallied somewhat during the day; but on the same
evening, without any warning, immense hemorrhage occurred from the mouth,
and he succumbed in a few minutes. The necropsy revealed a longitudinal rent
of two-fifths of an inch in the oesophagus, about four inches above the cardia. at
right angles to which was found a needle about two inches long, piercing both
walls of the descending aorta from before backwards. Both punctures were cov-
ered by small, firmly adherent blood-clots. The surrounding tissue, from the
oesophageal to the posterior pharyngeal wall above, was infiltrated with sanguineous
ichor. In the oesophagus were found large blood-clots, the stomach was completely
filled with a large coagulum of blood, and the whole intestinal canal contained
large masses of clotted blood.
The needle, which was swallowed with the bread, became fixed in the oesopha-
gus, and caused the moderate pain of the first few days. By repeated acts of
swallowing it was made to penetrate the aorta ; hence the bleeding on the 7th.
The clots then formed served for a couple of days to plug the punctures ; but
when they became decomposed under the influence of the food taken, there
resulted further and fatal hemorrhage. — London Med. Record, Jan. 15, 1878.
On Surgical Treatment of Bronchocele.
At a meeting of the Vienna branch of the Niederosterreich Medical Society
{Allg. Wien. Med. Zeit., November 27), Hofrath Prof. Billroth detailed his
experience in the operative treatment of bronchocele. The treatment by the local
and general use of iodine, he observed, is sometimes effectual, but only when the
individual is young and it is resorted to sufficiently early. It is now about ten
years since the practice of injecting the tincture of iodide into parenchymatous
bronchocele was introduced by Schwalbe, Liicke, and others, and it was soon found
that the apprehended danger of the practice was groundless. In some individuals,
however, violent reaction may occur, but in others not the slightest. Prof. Bill-
roth injects first from one-third to one-half of a Pravaz syringeful of undiluted
tincture of iodine, and, if this is well borne, in five or six days he makes a second
injection of one-half or a whole syringeful, repeating this twice a week. If the
patient becomes thin the treatment should be immediately stopped, as the ema-
ciation may go on to an important degree. It should also be stopped if haemop-
tysis appears. In general, the injections are well borne, and exert remarkable
influence. They may be tried when suffocative symptoms have appeared, if the
patient is kept under constant inspection; and even in cases about to be operated
upon their employment has been followed by recovery. It is essential that the
iodine be injected well into the substance of the bronchocele, which may be done
rapidly, the pain at the most continuing for five or ten minutes, and recmiring
cold applications, while in many cases it is entirely absent.
For cystic bronchocele Prof. Billroth has operated fifty-two times. On two
occasions he simply tapped it with a middle-sized trocar, and in both cases intense
inflammation arose, rendering incision necessary in one, and extirpation in the
other. He has abandoned the practice, but regards puncture for the purpose of
diagnosis as harmless. Tincture of iodine, after the fluid has been allowed to
o . . .
discharge itself without squeezing the tumour, has been injected in thirty-four
cases, with twenty-nine recoveries, half an ounce of that of the British Pharma-
copoeia (which is nearly twice as strong as that of the Austrian) having been
thrown in. The patient is then sent to bed, and a pretty firm calico bandage
smeared with collodion bound round the neck. This, in general, falls off on the
third day, and at first great swelling and accumulation of gas occur, but when
1878.]
Surgery.
551
these diminish during the first week there is no need of interference. The ab-
sorption sometimes takes place very slowly, occupying often a whole year. The
walls of the cyst do not adhere together consequently upon reaction, as has been
represented both with regard to bronchpeele and hydrocele, but the lining mem-
brane ceases to secrete in consequence of the deposition of iodine. Incision with
drainage was successfully performed in two cases ; and in twelve Chelias's opera-
tion of incision and connection of the walls of the cyst and the skin by sutures
was resorted to, nine of the cases being cured and three patients dying. The painful
procedure of cauterizing by chloride of zinc was once resorted to. In one case
in which pure alcohol was injected, fearful acetic fermentation was set up, and
the patient soon died in a septic condition. In two cases a diminution of the
tumour was produced by puncturing with a medium-sized trocar; but in a third,
suppurative inflammation was set up. which rendered incision necessary. Of
thirty-seven cases in which extirpation was performed, twenty-four recovered ;
but in some of these other measures had been previously resorted to, which had
induced suppuration. The arteries were immediately tied so as to often reduce
the hemorrhage to a minimum. Allusion was made to Rose's observation of the
diminution of the thickness of the cartilages by pressure, so that the trachea may
become as thin as paper, and therefore easily compressible, which often leads to
unexpected death after successful operations for bronchocele. Unfortunately it
is in the worst cases that this operation fails to preserve life, as asphyxia often
recurs, which may require tracheotomy, etc. In four or five cases in which this
was resorted to early, the patients nevertheless all died. It is in this operation,
as after opening large abscesses in the neck; or after tracheotomy in croup — the
patient, after going on well for some time, finally dies in a hitherto unexplained
manner with the symptoms of asphyxia.
The general result of Prof. Billroth' s operative procedures in bronchocele is,
that of ninety-four patients eighteen died, or about 19 percent., which, he ob-
serves, cannot be regarded as a bad statistical proportion, if the dangers to which
the subjects of the disease are exposed be considered. — Med. Times and Gaz.,
Jan. 12, 1878.
Tracheotomy in Diphtheria.
In an article in M. Langenbeck's Archiv, Bd. xxi., Dr. R. A. Kroxleix
gives some most valuable statistical data as to the value of tracheotomy in diph-
theria, and as to other points connected with this disease, founded on the enor-
mous number of 567 cases, which were admitted into Professor von Langenbeck's
clinic at Berlin from January 1, 1870, to July 31, 1876.
Tracheotomy was performed 504 times, the sole indication for the operation
being the presence of laryngeal stenosis, without reference to the patient's age or
the other features of the disease. Of these, 357, or 70.8 per cent., died. Eighty-
five operations were performed on children under two years, the youngest child
being only seven months old, and of these eleven recovered.
Kronlein finds, from the statistics of 241 carefully recorded cases, in 210 of
which tracheotomy was performed, that it is a bad prognostic sign if the breathing-
does not become perfectly free after the operation. Forty-two out of forty-six
children, whom it thus failed to relieve, died. The cause of the failure is either
the presence of lobular pneumonia or of croupous exudation extending far into
the bronchi ; but even if branching casts of the bronchi are expelled during the
operation, and the respiration becomes apparently quite free, the prognosis is still
unfavourable- Out of 210 children on whom tracheotomy was performed, 154
died ; and of these deaths 100 were due to asphyxia, and the remainder either
to a gradual loss of strength or to sudden collapse. Gradual loss of strength is
552
Progress of the Medical Sciences.
[April
largely induced by disturbances of the mechanism of deglutition, which Dr. Kron-
lein divides into two classes.
By far the larger number of cases belong to the first, in which swallowing is
impaired at a time when distinct diphtheritic exudation is still present in the
larynx, the functions of the muscles being interfered with by diphtheritic infiltra-
tion and exudation into their substance.
In the cases in the second class deglutition is affected much later, after the local
disease has completely healed, by secondary diphtheritic paralysis of the laryngeal
and pharyngeal muscles.
Returning to the general statistics of the whole 567 cases included in the
report, we may say that 377, or 66.4 percent., ended fatally, but that, though the
number of individual cases has increased year by year, the proportion of deaths
has diminished instead of increasing. Season affects the. prevalence of diphtheria
at Berlin very decidedly, the largest number of cases occurring in October, and
the smallest in June.
The period of life, when diphtheria is most frequent is early childhood. The
number of cases steadily rises from one month up to three years old, when the
maximum frequency is reached ; from that time until the end of the fourth year
there is little variation, but in the fifth year the numbers gradually decline until
the fifteenth or sixteenth year is reached, after which time cases become extremely
rare. Out of the 567 cases in Kronlein's report only eight occurred between the
ages of eighteen and forty-one years.
Various local remedies, which were tried with a view to arrest the spread of
the diphtheritic exudation, all failed to give a satisfactory result. — Med. Times
and Gaz., Feb. 2, 1877.
Laryn go-Tracheotomy for Large Multiple Papillomatous Growth in the Larynx;
Removal of the Vocal Cords ; Preservation of Voice ; Coexistence of Thoracic
Aneurism.
At the meeting of the Clinical Society of London held on February 2. 2d (Med.
Times and Gaz., March 2, 1878), Dr. Burnet Ye o introduced the subject of
the above operation. He was a labouring man, aged forty-nine, and who first
came under his observation as an out-patient at the Bronvpton Hospital on Octo-
ber 13 last, complaining of severe and almost constant pain at the upper part of
the left side of the chest He was very hoarse, and had been so for eight or nine
years. He suffered much from dyspnoea, and could not lie down in bed. Ex-
amination of the chest discovered a distinct pulsation at the sternal end of the
second left intercostal space, with a corresponding area of dulness and strongly
accentuated second cardiac sound. There was also a prolonged, noisy, harsh,
and sometimes whistling inspiration heard all over the chest, without any moist
rales. Laryngoscopic examination disclosed the existence in the larynx of a
large vascular warty growth, apparently pedunculated, and attached to the ante-
rior commissure above the vocal cords. It almost completely filled the upper
part of the laryngeal cavity, concealing the glottis and the vocal cords entirely,
except during breathing, when a triangular interval could be seen between the
growth and the left vocal cord, through which air passed into the air-passages.
On the 16th he was admitted into King's College Hospital, when, amongst other
points in his history, he mentioned that, in June last, while helping to pick up an
iron rail, he heard something crack, and was suddenly seized with severe pain in
the superior cardiac region, from which he had ever since suffered. He was kept
at rest in bed for a month, without any amelioration in his condition ; indeed,
the pain in the chest and the difficulty of breathing were so distressing that the
patient begged for some operative interference. After consultation with Mr.
1878.]
Surgery.
553
Lister, the operation which he immediately described to the members was per-
formed on November 23.
Mr. Lister then described the operation which he had performed. Crico-
tomy having shown that both vocal cords were implicated in the disease, he at
once divided the thyroid cartilage, after introducing into the trachea one end of
a bent leaden tube packed with thin sheet India-rubber, so as to plug the canal
completely and prevent danger from blood entering the air-passages, chloroform
being given at the other end of the tube. Both vocal cords were removed entire,
together with neighbouring portions of mucous membrane, including the false
vocal cords. The sides of the thyroid cartilage were drilled and tied together
with silver wire, and the edges of the skin over the thyroid cartilage were kept
in a state of relaxation by means of the button-stitch. The great peculiarity of
the case consisted in the fact that the patient retained the power not only of
coughing, but of speech of considerable power. In order to explain this, Mr.
Lister referred to observations upon the movements of the larynx, which he had
made in 1861, and published shortly in the article " Anaesthetics" in Holmes's
Surgery. He had then ascertained by laryngoscopic examination in his own
person, after an experiment on one of the lower animals, that the pulpy folds of
mucous membrane which surmount the summits of arytenoid cartilages can be
carried forward to the base of the epiglottis by an antero-posterior movement of
the cartilages not generally known to occur, so as to act as a secure valve to the
opening of the respiratory passage. It is the vibrations of these posterior parts
of the aryteno-epiglottidean folds which constitute the mechanism of laryngeal
stertor ; and it is by their means that the exit of air is prevented during the accu-
mulating pressure in an expiratory act which ends in coughing. Mr. Lister be-
lieved that it was still not generally known that the strain of the act of coughing
is not borne by the delicate apparatus of the rima glottidis, but by these folds of
mucous membrane which cannot suffer from such treatment. Knowing this fact,
he had anticipated that the patient would be able to cough like other people ; but
he had not expected him to retain the power of speaking above a whisper. Yet
he might have been prepared for the possibility of such an occurrence, seeing that
laryngeal stertor can be produced at will, and by a mechanism which is inde-
pendent of the vocal cords, and was left intact by the operation. Mr. Lister then
himself uttered a sentence in a voice produced by the vibrations of the aryteno-
epiglottidean folds ; and he stated that, since his attention had been directed to
the subject, he had noticed that this kind of voice is occasionally resorted to in
ordinary parlance under the influence of mental emotion.
When the patient was introduced, the linear cicatrix over the box of the larynx
having been exhibited, he. showed that he could cough naturally, and also spoke
some sentences in a deep, gruff monotone, plainly audible to all present.
The patient was then introduced ; and Dr. Burney Yeo added, in completion
of the history of the case, that inspection with the laryngoscope now showed an
entire absence of the normal inter-laryngeal structures. In attempts at speech,
the aryteno- epiglottic folds were drawn towards the median line, and served as
vibrating media. He had been readmitted into the hospital a few weeks ago on
account of the same neuralgic pains caused by his aortic aneurism, the physical
signs of which had become more evident. He had been treated by rest in bed,
hypodermic injections of morphia to procure rest at night, and iodide of potassium
in doses of thirty grains three times a day. He had much improved under this
treatment ; he was now able to lie down comfortably in bed on either side. He
had no dyspnoea and no cough. The expansile impulse and the area of dulness
were less. Dr. Yeo thought the case of great interest, not only on account of the
curious physiological fact it had revealed with respect to the production of voice,
No. CL April 1878. 36
554
Progress of the Medical Sciences.
[April
but also from the remarkable coincidence of the existence of these large intra-
laryngeal growths together with thoracic aneurism. In prelaryngoscopic times it
would have been difficult to have avoided the error of regarding the hoarseness
and the obstruction to respiration observed in the case as consequences of aneu-
rism al pressure. It was another instance, and a very remarkable one, of the
clinical value of the laryngoscope.
Mr. Holmes said that the case would have been more complete had any ana-
tomical proof been given of the entire removal of the vocal cords, especially as
in the ordinary operation of thyrotomy, for the removal of warty tumours from
the larynx, no necessity was generally found for doing more than removing at
most their surfaces. He also said that, in reference to the supposed power of the
aryteno-epiglottidean folds to produce vocal sounds by their vibration, it would
be interesting to know whether any laryngoscopist had ever observed such vibra-
tions during the production of the hoarse voice which Mr. Lister imitated, or
during any other kind of phonation. Mr. Lister's own experiments, of course,
referred to a peculiar and forced position of the tongue, and to the production of
a mere inarticulate sound.
Mr. Lennox Browne said, that having had an opportunity of examining the
patient, he could bear testimony to the fact that every portion of the vocal cords,
true and false, had been removed. It appeared to him that in the act of phona-
tion in this case there was general lateral compression of the larynx; there was
certainly also a disposition for the epiglottis to hang lower than before the opera-
tion, so as to come in greater proximity to the arytenoid cartilages. The case
was exceedingly interesting and important because the operation had been per-
formed, not only on account of impairment of voice, but for relief of a vital symp-
tom ; and although there were dangers in the operation, they were in point of
fact not so many nor so great as were frequently witnessed in attempts to remove
growths per vias naturales. In this latter operation he had personally witnessed
the following consequences : Spasm of the larynx, resulting from the introduction
of instruments, in two instances requiring immediate tracheotomy; removal of
normal tissue, leading to ulceration ; injury to laryngeal cartilages, especially the
arytenoid, resulting in paralysis, caries, and death of the patient. There was
further a much greater tendency to recurrence than was generally supposed, and
the recovery of voice was by no means so complete as was frequently thought to
be the case by those who had not an opportunity of personally witnessing the
results. Mr. Browne considered that the removal of the tracheal tube so very
shortly after the operation in the present instance had contributed greatly to the
patient's rapid recovery, while the very complete enucleation of the contents of
the larynx would lead one to predict with almost certainty that there would be
no recurrence ; and he believed that were these two points, justly insisted on as
important by Professor Lister, rigidly adhered to in similar cases, there woukl be
no necessity for the much more dangerous operation of extirpation of the larynx.
Mr. Lister, in replying, said that, with reference to Mr. Holmes's remai'ks, he
must beg Mr. Holmes to take his word for the fact that both vocal cords were
removed in their entire length and thickness, including the anterior processes of
the arytenoid cartilages into which they are inserted ; or, if that were not suffi-
cient, he would appeal to Dr. Yeo, who was present at the operation. Mr. Wood
also kindly assisted at the operation, and, if he had been at the meeting, he would
have confirmed the accuracy of the statement.
Dr. Burney Yeo, in replying, said there could be no doubt whatever that the
whole of the strictly intra-laryngeal structures had been removed by the opera-
tion. He had had opportunities of demonstrating this fact laryngoscopically to
several gentlemen present. The patient had not made so good an appearance
1878.]
Surgery.
555
that evening as be had done on other occasions, being probably a little disturbed
by coming before so large an assembly ; but his voice had been tested in every
way, and he was able to pronounce all the vowel sounds, and to read distinctly
anything that was put before him. »
A Case of Total Extirpation of the Larynx ; Death on the Fourth Day.
Dr. Gerdes reports (Archie fur Klin. Chir., Bel. xxi., Heft 2, 1877), a case
of extirpation of the larynx in which the patient had suffered for many years
from hoarseness, but only since May, 18 7G, from dysphagia, and a slight inter-
ference with respiration. The laryngoscope showed that an irregular grayish-
coloured infiltration occupied the right side of the larynx, extending from the vocal
cord upward to the level of the edge of the thyroid cartilage ; the left side of the
larynx was free. Epiglottis normal. In spite of the absence of other character-
istic appearances, the infiltration described gave the impression that it was of a
malignant nature, and its removal was proposed to the patient, but refused. On
the 10th of February following, dyspnoea and dysphagia had reached such a grade
that tracheotomy was necessary ; great difficulty was found in causing the tube to
retain its proper position after introduction, and finally, after many attempts,
lasting two to tln*ee weeks, it was removed permanently, and the wound allowed
to close.
On the 28th of March, 1877, the patient was again seen; the tracheal wound
had not entirely closed ; the dyspnoea was excessive, and the laryngoscopic exami-
nation demonstrated a marked increase in the size of the growth — so much so,
that more than one-half of the lumen. of the trachea was occupied by it. The
operator now determined to lay open the laryngeal cavity, assure himself as to the
nature of the neoplasm, and then either remove it by the knife or sharp spoon, or,
if it appeared advisable, to extirpate the larynx.
March 30th, the operation of extirpation was performed. The patient was
placed in the position advised by Maas, Trendelenburg's canula being used, and
the various steps of the operation being followed out as already described in other
instances (a detailed account is given in the original article).
The degeneration of the extirpated larynx was even more extensive than was
supposed from the laryngoscopic examination. The neoplasm occupied the entire
right half of the larynx, extended thence to the left, and formed a large tumour
below the vocal cords, altogether reducing the lumen of the larynx to a very
narrow slit. The cartilages were in great part involved in the destructive process,
presenting in many places the thickness alone of a thin paper, without, however,
being perforated at any point- The microscope demonstrated epithelial cancer.
The patient did badly after the operation, and died on the morning of the 3d
of August, of collapse (fourth day after the operation). — New York Med. Jonrn.,
Feb. 1878.
A Simple Plan of Emptying the Pleural Cavity.
Simplicity is a merit even in surgery, and hence the method of evacuating
pleuritic effusions recommended by Dr. Girgensohn, of Riga (Berlin. Klin.
Woch., No. 48, 1877), deserves notice. He taps the chest with an ordinary
canula and trocar, withdraws the latter, and slips over the end of the canula a
caoutchouc tube three to six feet long, and of a suitable diameter, closed at the
lower end with a clip or a small stopcock, and filled with a one to two per cent,
solution of carbolic acid. The tap is then opened under the surface of a solution
of carbolic acid in a large vessel placed at a lower level than the opening in the
chest, so that the tube is converted into a siphon. A serous effusion of six to
556
Progress of the Medical Sciences.
[April
eight pounds weight can be in this way evacuated in a quarter of an hour. If the
stream stops from any cause, the tube can be alternately compressed and allowed
to expand, so as to exert a pumping action on the fluid higher up. Where it is
absolutely essential to prevent air entering the chest, Girgensohn recommend- tin-
trocar to be passed through the wall of the caoutchouc tube, into the upper end
of which the canula is tied ; the tube is then filled with carbolic solution from a
funnel inserted into the raised lower end, so as to completely expel all air. The
trocar is inserted with the canula into the chest, and withdrawn gradually until
the necessary communication between the chest and the tube is established, and
then completely withdrawn, and the tube slipped forward over the canula and
tied, so as to close any opening left by the trocar. The fluid is then drawn off
siphon-fashion as before. The author claims for his method the advantages of
simplicity, of avoiding the continued presence of a sharp instrument in the chest
during the operation; of being uniform in its action and easily regulated; and,
lastly, of permitting the whole apparatus used to be cleansed and kept in order
without the slightest trouble. — J\Ied. Times and Gaz., Dec. 22, 187 7.
A Successful Case of Extirpation of the Spleen.
Dr. A. Martin, of Berlin, reports (British Medical Journal, Feb. 0, 1K78)
the case of a poor hunchback woman, thirty-one years of age, who applied to him
on account of the severe pain which she suffered from a wandering spleen. Micro-
scopical examination of the blood showed its constitution and the numerical relation
of the red corpuscles to the white to be normal. The spleen was not enlarged ;
it could be felt per vaginam. The pains were constant and intense, continued
even when the patient herself seemed unconscious from chloroform, and could not
be diminished by drugs or other means.
On May 13th, 1877, the spleen was extirpated under the antiseptic method.
Before the patient was placed on the table, the spleen was pressed into the median
line. This being done, chloroform was given. The incision, which was in the
median line, was about four inches in length, extending from the umbilicus down-
wards. The walls of the abdomen were extremely thin. Under the peritoneal
opening, the omentum presented, but the spleen had disappeared ; after some diffi-
culty, it was found in its normal place. Dr. Martin was astonished to find how
difficult it was to bring the organ out of this position and through the incision. The
hilus was occupied by a group of vesselsr which seemed to be quite separated from
each other and to run free of all connections with neighbouring organs a distance of
about four inches. The group next the lower surface of the organ contained one
large artery. This he tied as firmly as possible with a silk ligature. Then he took
the middle group, containing some arteries and the splenic vein, which was about
the size of a thick goose quill. The ligature was carried around it in the same
manner as in the case of the other vessels. While ligaturing the third group, the
silk broke, wounding a small artery. In a moment, a hematoma was formed by
the blood effused into the peritoneal layer around the vessels. He now tied the
vessel further from the spleen, and stopped all bleeding completely. He next cut
through the vessels and took away the spleen. Although the bleeding had ceased,
he surrounded the vessels with a thick silk ligature, and fastened the whole once
more. After this, there was no bleeding whatever. After cleaning off the dif-
fused blood, he dropped the pedicle, which had commenced to swell most fearfully,
back into the cavity. This being quite clean, he closed the abdominal walls and
covered the wound with antiseptic dressing. Twenty-eight minutes after the ope-
ration was commenced, the patient awoke in her bed feeling quite comfortable.
The removed organ was only a little larger and heavier than normal ; it was
densely covered with star-like old and recent superficial cicatrices of perisplenic
1878.]
Surgery.
557
inflammation. The parenchyma itself was not changed, nor was the blood the
vessels contained pathologically changed.
The patient recovered without any febrile reaction. Being accustomed to the
use of morphia, she received, during the first three days, several doses per diem.
For the first day, she took only small pieces of. ice. On the second day, the
bowels began to act spontaneously ; then she had beef-tea and wine. On the
fifth day, she felt so well that, during the momentary absence of the nurse, she
left her bed to look out of the window On the fourth day, the bandages were
changed under carbolic spray, the wound having healed almost completely per
primam intentionem. On the ninth day, she felt so well that she could not be
detained in bed anV longer, and on the eleventh day she was sitting in the sunlight
at the door of the clinic. The patient felt extremely well ; the old pains, which Dr.
Martin believed to be caused as well by the chronic inflammation as by the tension
of the peritoneum by the organ, had disappeared, nor were any functions of the
body disturbed. In different preparations, Dr. M. examined her blood microscopi-
cally, and sometimes in these examinations he was favoured with the kind assistance
of Dr. Gravitz, of Virchow's Pathological Institution : but they found no alteration
of the corpuscles, either in form or behaviour, nor in their relative number, nor was
the fluid changed from its state previous to the operation. During the third week,
the patient suffered serious indigestion from improper food. The menses were
postponed six weeks, as has frequently occurred before ; and the flow was not so
profuse as during the former periods. Dr. M. was the more satisfied by the rapid re-
covery of the patient, for there thrombi were surely to be expected to form in the
long splenic arteries, and he feared serious trouble therefrom. Nevertheless, no
symptoms of any danger could be discovered, and three weeks after the operation
the patient returned to her work, and at every opportunity hastened to show her-
self to those who had previously treated her.
Extirpation of Kidney.
The following case is reported by Professor Kochee, of Bern, in the Deutsche
Zeitschrift fur Chirurgie, Band ix. Heft 3 and 4. A child, aged two years and
a half, was brought to the author on July 10th, for treatment of an abdominal
swelling which had commenced shortly after birth, and had subsequently in-
creased slowly in size. The abdomen, when the child was first seen by Dr. Kocher,
presented a very prominent tumour on the left side. The right side of the abdo-
men was lax and tympanic, the left side very resistant, and occupied by a well-
marked growth, which extended upwards behind the margin of the ribs, whilst
its inner margin, which was rounded, stretched from the umbilicus outwards and
downwards to the middle of Poupart's ligament on the left side. No intestine
could be felt in front of this tumour. The growth seemed to be spherical and
very firm, and its surface was felt to be studded with cylindrical projections. It
was freely movable upwards and downwards, and slightly so towards the median
line. The urine was normal. Puncture of the swelling was attended with but a
negative result, as the discharge consisted merely in some drops of blood. The
case was diagnosed as one either of foetal tumour, of splenic tumour, or of a large
new growth in the left kidney. On September 27th, after chloroform had been
administered, the abdominal wall was incised, as in the operation of ovariotomy,
from the apex of the ensiforni process to a point midway between the umbilicus
and the symphysis pubis. After the protrusion of a large mass of distended in-
testine, the tumour was exposed, the parietal layer of peritoneum in front of it
being found much thickened, and traversed by very many large vessels. This
peritoneal covering having been divided and carefully dissected from off the tumour,
the whole mass was readily shelled out from the fatty and connective tissue in the
558
Progress of the Medical Sciences.
[April
left lumbar reg-ion. The growth was then found to be connected with the left
kidney, and was continuous with a short pedicle. This having been secured in a
double catgut ligature, and then divided, the whole of the disease was readily
removed. The peritoneal cavity having beenv carefully cleansed, the intestines
were replaced, and the edges of the extensive wound brought together by twenty
catgut sutures. The little patient rallied quickly from the immediate effects of
the operation, but on the following morning was very feverish. On the evening
of the second day there was collapse, and on the next day, after a slight attack
of convulsions, the child died at 1 P. M. At the post-mortem examination, traces
of slight peritonitis were found. There was no fluid effusion into the cavity of
the peritoneum, but the coils of intestines were glued together and to the abdom-
inal walls by shreds of soft fibrinous material. Professor Kocher attributes the
fatal result to this peritonitis, and not to uraemia. There was compensatory
hypertrophy of the right kidney, and the convulsions observed shortly before
death were slight, and not characteristic of ura?mic poisoning. The operation
was performed under antiseptic conditions, and the wound was carefully covered
by antiseptic dressings \ but, during the process of enucleating the tumour, the
large mass of protruded intestine was not, the author thinks, sufficiently protected
from atmospheric influences.
The tumour, which weighed 1405 grammes (about three pounds), was exam-
ined by Professor Langhans. It was found to be inclosed in a tough capsule,
and had evidently started from the centre of the kidney, as its superficial portion
presented a thin streak of renal tissue, which was in direct contact with the cap-
sule. The proper structure of the tumour was soft, of a reddish-gray colour, and
infiltrated with an abundant thin and clear juice. This structure, on microscop-
ical examination, presented two elements ; epithelium arranged in the form of
gland-tubules, and a tissue very rich in cells and nuclei, and corresponding to
embryonal connective tissue. Sparsely scattered in some parts of this latter tis-
sue were to be seen fibres of striated muscle. The tumour was classed by Pro-
fessor Langhans as an adeno-sarcoma.
Professor Kocher states that but one other case has been recorded of removal
of the kidney on account of new growth. In the twelve cases of nephrotomy re-
ported by Nepveu (Archives Gine'rales de Me'decine, Fevrier, 1875), the opera-
tion was performed for other renal lesions, and, in the majority, in consequence
of a wrong diagnosis. Notwithstanding the results of the operation in his two
cases, the author argues in favour of the performance of nephrotomy in the treat-
ment of renal cancer. The following facts in connection with this disease bear,
he holds, on the question of treatment by operation : In 50 only out of 115 cases
investigated by Rohrer were metastatic and secondary growths found after death ;
both kidneys were found involved in ten per cent, only of the total number of
cases. Renal cancer occurs very frequently in early life, the subjects, in one-
third of the number of cases, being under the age of ten years. If the growth be
diagnosed at an early stage and when it is small, it may be readily removed
through an incision made from behind in the lumbar region.— London Med.
Record, Feb. 15, 1878.
Case of Congenital Ventral Hernia successfully treated.
In the Bidletino delle Scienze Medicale di Bologna, vol. xxiii. (abstract in
Annali Universali di Medicina, December, 1877), Professor F. Rizzoli de-
scribes the case of a male child, which had an opening occupying the umbilical
and a great part of the epigastric regions. It was ovoid, its direction was vertical,
and its boundary comprised the entire thickness of the skin and of the abdominal
wall. Through this abnormal aperture the abdominal viscera escaped, especially
1878.]
Surgery.
559
when the child cried, and were covered by the amnion and by Wharton's jelly.
The skin around the sac was not continued over it, but was arrested at the same
point as the abdominal wall. This, and the large size of the aperture, were con-
ditions very unfavourable to the success of an operation. Dr. Rizzoli, however,
undertook the treatment. He ordered the mother to avoid everything that might
cause the child to cry : to give it milk frequently, but in small quantities ; to em-
ploy ordinary means for the evacuation of the meconium ; and above all, to pre-
vent the escape of the viscera through the aperture. The part was covered with
a piece of silken cloth, moistened with water and smeared with butter, and the
surface of the sac was frequently bathed. The dressing was secured by a bandage
round the abdomen, which, while it favoured the retention of the bowels, did not
draw the edges of the aperture together. This arrangement was made in order
to prevent the formation of a too small cicatrix, which might render the abdominal
cavity too small to contain the viscera, and produce disastrous results, such as
occurred in a case recorded by Goyrand, where death was caused by volvulus ;
and in one by Requin, where an inguinal hernia was formed on each side.
Under these precautions, after the amnion and the stump of the umbilical cord
had fallen off, the surface of the sac became gradually covered with granulations,
and cicatricial tissue advanced gradually from the border of the ventral aperture,
covering it in completely, and retaining the viscera in the abdomen without the
least injury. The ovoid cicatrix, when the report was made, was 0.6 inch long,
0.7 7 inch wide, and 2.2 inches in circumference.
When the child was eight months old, Dr. Rizzoli showed it to the Medico-
Chirurgical Society of Bologna. It was then in florid health, and the umbilical
cicatrix was sound. — Lond. Med. Record, Jan. 15, 1878.
Excision of Hard Chancre as a Preventative of Syphilitic Infection.
Auspitz (Archiv fur Dermatologie und Syphilis, 1 and 2 Heft, 187 7), excised
the primary induration of syphilis in 33 cases. In 4 the result could not be ob-
served ; in 2, constitutional syphilitic symptoms were present at the date of the
excision, and the disease followed its usual course ; and in 4 the result is still
doubtful. Of the remaining 23 persons 9 were nevertheless affected subsequently
by syphilis, but in 14 cases within a sufficiently long period of observation after
the excision no syphilitic symptoms had developed, and in these the excision may
be held to have preserved the individuals from constitutional disease. Induration
of the inguinal glands did not interfere with the success of the measure. The
author believes that, if the excision had been practised at an earlier stage, the
proportion of successful cases would have been larger. Those cases in which the
wound healed without fresh induration remained, as a rule, free from syphilis.
The author infers from the results that neither the primary induration nor indolent
swelling of the inguinal glands is a proof of general infection of the organism. —
Load. Med. Record, Dec. 25, 187 7.
Syphilis of the Testis in Young Children.
Dr. Henoch (Deutsche Zeitschrift fur Prakt. Med., 187 7, No. 11) observed
seven cases of disease of the testis in syphilitic children. In one case, where
death took place from cholera, there was an extensive interstitial hypertrophy of
the cellular tissue, especially in the corpus Highmorianum. Henoch concludes
from this case and from one described by Depres, that in the earlier stages of in-
terstitial orchitis a cure by mercury is possible ; but, when fibroid new growth has
taken place, no further change is to be expected. The ages of the children varied
from three months to two years and a half; both testes were affected in four cases,
5 GO
Progress of the Medical Sciences.
[April
and the left in three. Tuberculosis of the testis, of which Henoch saw four
cases, always presented a hard nodular swelling- confined to the epididymis, and
was always accompanied by pulmonary tuberculosis or cheesy inflammation of the
bones, while symptoms of syphilis were always absent. — British Med. Journal,
Dec. 8, 1877.
Congenital Malposition of the Testicle successfully treated by Operation.
Mr. Thomas Axxaxdale, at a late . meeting of the Medico-Chirurgical
Society of Edinburgh (Edin. Med. Journ., Jan. 1878), exhibited a photograph
of a rare congenital malposition of the testicle in the perineum, in which, as far
as he knew, this malformation had been for the first time successfully treated by
operation. One or two cases were on record where the attempt had been made
to replace the displaced organ fully into the scrotum, but always without success.
He believed his own success to be due to the use of antiseptics, meaning by this
the Listerian method. He made an incision over the displaced testicle and drew
it out, together with the tunica- vaginalis. One interesting fact was. that the part
of the gubernaculum testis, usually attached to the bottom of the scrotum, was in
this instance fixed to the ischial tuberosity. He then incised the scrotum and
plaeed the testicle there, retaining it by means of a catgut stitch. At the same
time he subcutaneously stitched up the opening in the perineum also with catgut.
The result was satisfactory, and the testicle was now in all respects like the one
on the opposite side.
Prostatic Tumours removed during Lithotomy.
Mr. Thomas Bryant, at a late meeting of the Pathological Society of London
(Med. Times and Gaz., Feb. 16, 1878), exhibited specimens of prostatic tumours
which he had removed successfully during lithotomy. The first specimen was
from a man of sixty-seven, who was operated on in Guy's Hospital in January.
1875, after having suffered from symptoms of vesical calculus for eighteen months.
The blunt gorget was used ; the stone was caught, and found to be large ; a resist-
ance was felt, and discovered by the finger to be a prostatic tumour situated be-
tween the stone and the hinge of the forceps. The whole was removed, when
the calculus proved to be one inch and a half in diameter, and the tumour to con-
sist of prostatic tissue and muscular fibre. There was no hemorrhage, and recovery
was perfect. The second specimen was removed from a gentleman of seventy
years, who had suffered from vesical symptoms for four years, and was extremely
ill. Lithotomy was performed ; the gorget had to be used ; and the stone, when
seized, could not be extracted. A portion of the prostate was then ascertained
to be in the way, when, by rotation of the forceps and pressure backwards on the
tumour, the hinge of the instrument caught the growth, and both it and the cal-
culus could be extracted. The patient was perfectly well in six weeks. The
growth consisted of prostatic tissue. Mr. Bryant said that in both these cases
the patients had been relieved of stone and of another cause of distressing symp-
toms by a single operation. Convalescence was not affected by the operation. In
other words, benefit seemed to have followed the removal of prostatic tissue. It
appeared to him that in a similar case the surgeon might follow his practice, or
even search for the condition ; but he would hardly suggest operation for the relief
of symptoms due to enlarged third lobe of the prostate. The operation had first
been mentioned by Sir William Fergusson thirty years ago.
1878.]
Surgery.
561
Treatment of Cystitis.
Mr. Robert Persse White, Surgeon to the Meatb Hospital, advocates
{Dublin Journ. of Med. Science, Jan. 1878) the treatment of cystitis by in-
jections of a weak solution of borax (half a grain to the ounce of warm water).
His experience has shown him that the whole '"role" of treatment hitherto
practised is of little avail.
Pseudo-Membranous Cystitis and its Treatment.
Thi^ variety of cystitis is generally met with after the application of blisters.
It is. however, sometimes found in the case of chronic and long-standing lesions
of the bladder, such as calculi, tuberculization, and muco-purulent cystitis. The
nature of the false membranes thus expelled with the urine has been sufficiently
discussed. After it had been long admitted that they were the result of an ex-
foliation of the mucous membrane, it was afterwards sought to be demonstrated
that they were almost always formed by fibrine, inclosing epithelial cells. This
opinion is defended by M. Girard, and it seems the most rational ; however, he
admits, with Dolbeau. the exfoliation of the mucous membrane by fragments ;
but as a very rare phenomenon. The treatment consists specially in repeated
washings out of the bladder, followed by slight cauterization with a weak solution
of nitrate of silver, which is left in the bladder during one or two minutes. M.
Guyot {These de Paris, 1877) obtains neutralization with water in which salt
has been dissolved. M. Guyot also seems to have succesfully employed a solu-
tion of borax, of tire strength of one part to tire hundred, in place of the nitrate
of silver. — Lond. Med. Record, Dec. 15, 187 7.
The Pathological History of Cysto-Phosphatic Deposits.
Sir Hexrt Thompson, in a short paper on this subject {Lancet, Jan. 12 and
19, 1878), gives the following as the conclusions at which he has arrived in rela-
tion to this subject: —
1. That, in its healthy condition, the bladder rarely, if ever, retains, but, on
the contrary, expels all phosphatic deposits.
2. That, when the bladder is not healthy, but affected by chronic inflamma-
tion, provided it is not considerable nor very prolonged in duration, the power of
expulsion is still almost as great as in the healthy organ.
3. That there is a diseased condition of the inner coat of the bladder, in which
its ability to expel phosphatic deposit is almost lost, and in which the formation
of concretions — and if these are neglected, of stone — is certain to occur. It by
no means infrequently happens after cystitis that the mucous coat acquires a mor-
bid condition, which is not so much one of actual inflammation as the result of
long continuance of that action. The membrane loses its polish, usually in one
or more circumscribed spots, and becomes abraded, roughened, even flocculent,
and exudation of lymph sometimes takes place on the surface. This matter,
which is extremely tenacious, and to which phosphatic salts strongly adhere, is
wholly different, it need hardly be said, from the ordinary and well-known A'iscid
mucus of the bladder. The latter has often been regarded, not without apparent
reason, as a mechanical agent for gluing together crystalline particles to form con-
cretions, although I doubt that it acts thus to any considerable extent. The
lymph exuded from an abraded spot becomes loaded with phosphates, attaching
them to tire surface beneath, from which the tenacious mixture is not easily
removed.
Let me illustrate the action which takes place thus. Every hospital student
502
Progress of the Medical Sciences.
[April
knows that if a new gum-elastic catheter be fastened into the bladder and left
there, the urine being healthy, no phosphatic deposit will occur during the first
day or so, on the small portion of the instrument which protrudes within the
cavity of the organ. If, however, the catheter remains for a considerable period,
whitish granules will appear on the surface at different points, and these in time
coalesce and form an enveloping crust. What is the rationale of the action?
Simply this : While the surface of the catheter was smooth and polished, no
phosphates appeared, but after the urine had partially dissolved and abraded the
varnished surface, making it slightly rough, and beginning to expose the fibrous
basis of the instrument (a process which takes place much more rapidly in ammo-
niacal than in healthy urine), the roughened surface determines the precipitation
of the salts upon it. The same thing occurs on the surface of a calculus as long
as it is retained within the cavity of the bladder, the urates or oxalates being
deposited while inflammation is absent, phosphatic salts when that change lias
taken place. And thus it is that in the rings of a cut calculus may be seen the
history of a patient's troubled life during the period of its formation, quiet inter-
vals showing one form and character of deposit, attacks of inflammation marked
by a white phosphatic ring, and so on. Another illustration is furnished by the
absence of deposit on a well-made India-rubber catheter, although retained for a
long period. Its surface resists the action of urine; if, therefore, the instrument
was smooth at first, no precipitate takes place. I have left, in very exceptional
circumstances, such a catheter for six weeks without removing it, and then found
it as free from deposit as when introduced.
Xow, these phenomena explain the reason why cysto-phosphatic deposits in
some cases obstinately persist and recur. So long as the mucous lining of the
bladder retains its polish, so long as no serious denudation of epithelium takes
place, no precipitated phosphates, as a rule, will be detained in the interior, pro-
vided the organ can empty iiself, or can be emptied artificially. No adhesion of
phosphatic material to the wall will result at any point, and consequently the
appearance of deposit is not in these circumstances a very serious matter. But —
and we shall see hereafter how closely this subject bears on the operation of
lithotrity — the moment the mucous coat of the bladder has notably lost in any one
spot its natural polish, has become denuded or roughened, so soon there is danger
that phosphatic salts will be attached to that spot, and become the fertile and con-
tinuous source of concretion-formation in the bladder. If degradation of the tis-
sues has gone far enough to permit the exudation of lymph, the condition approxi-
mates to that of ulceration, which, however, is rare in the bladder, and only
present in very severe or long-continued disease. An illustration of the action
which takes place in such circumstances may occasionally be observed after
lithotomy, when the urine deposits on the surface of the wound a phosphatic
coating, which adheres sometimes with great tenacity to the exuded lymph there,
while no deposit whatever occurs in the bladder itself. In those somewliat rare
instances of calculus partially encysted in a sac of the bladder, the small rough
surface which is exposed in the cavity acts in a similar manner. Phosphates are
deposited upon it, and when the aggregation has assumed a certain size, it is
detached, falls into the bladder as a concretion ; the process goes on at the original
spot, and may be repeated again and again.
Glycerine in the Treatment of Internal Hemorrhoids.
Dr. David Young, of Florence, recommends {Practitioner, Jan. 1878) the
use of glycerine, in two drachm doses night and morning, as an efficacious pallia-
tive for internal hemorrhoids.
1878.]
Surgery.
563
Ulcers from the Use of Enemata.
Professor Koester, of Cologne, lias an article on this subject in the Corre-
spondenzblatt, der Arztl. Vereine von Rheinland, ~No. 20, 1877. There is not
unfrequently found in the rectum an ulcer (hitherto observed only by Reckling-
hausen) differing in its appearance and its constant situation from all other known
ulcers of the intestinal tract. It varies in size, is usually round, frequently pene-
trating the intestinal wall like a funnel in a direction from below upwards, and
from without outwards ; there is little or no inflammatory proliferation of the
base and edges. It is always situated in the anterior wall of the rectum, generally
about two inches— never less than one nor more than three inches — above the
anus. Sometimes only the mucous membrane is ulcerated and undermined ;
sometimes the entire wall of the rectum is destroyed ; and in some cases there is
suppuration of the pelvic connective tissue. In many cases, fatal peritonitis may
be produced by perforation of such an ulcer ; and even puerperal peritonitis has
had its origin in rectal ulcer.
The form and situation of the ulcer indicate that it is of traumatic origin —
being, in fact, caused by the somewhat unskilful use of the enema-syringe. In
many cases the correctness of this supposition may be confirmed by inquiry. At
the part in question, the rectal folds of mucous membrane and the thickness of
the intestinal wall, and in front the prostate or uterus, and in puerperal women
the head of the child, present a resistance to the horizontal passage of the pipe.
This resistance to the mucous membrane is overcome by thrusting it aside ; but,
in doing this, there is risk of wounding it with the point of the syringe, and of
infiltrating the submucous or circumrectal cellular tissue with the injection.
The author finally shows that, according to the researches of Ribes, and the
observations of more modern surgeons, the opening of intestinal canal fistulas corre-
sponds with the situation of clysmatic ulcers in that the latter are never found in the
posterior wall, nor more than three inches above the anus. Hence it is probable
that a large number of fistulas of the rectum owe their origin to the enema-pipe. —
London Med. Record, Jan. 15, 1878.
Production of Local Artificial Anosmia as a means of Treating Diseases
in the Extremities.
Dr. Bernard Cohn's communication (Berliner MedicinischeWochensclirift
October 29, 1877) is founded on an attempt made in three cases to treat acute
and chronic inflammations in the extremities, by temporarily rendering the limb
bloodless by means of Esmarch's bandage.
Two of the cases reported were of an acute kind. One was an acute phlegmon
of the toe, with inflammatory swelling of the foot, in which, after only fifteen
minutes' application of the bandage, the inflammatory swelling and pain notably
diminished. The other case was a very painful diffuse inflammatory swelling of
the forearm. After one application of the bandage, the duration of which is not
mentioned, the pain, and, to some extent, the swelling, disappeared. Nor did
they reappear when the compression was removed. Some tenderness continuing,
the bandage was reapplied next day with a completely successful result. On these
two cases the author properly lays less stress than upon the following one. A
child 3^- years of age had suffered for eighteen months from a white swelling in
the knee. The disease had originated in a fall, and a well-marked acute stage had
been followed by a condition in which the chronic changes in the articulation,
defined as tumour albus, were quite characteristic. The joint was swollen, painful,
much flexed, and scarcely movable, either actively or passively. During twelve
months, treatment had been pursued both in private and at the polyclinic ; five
564
Progress of the Medical Sciences.
[April
gypsum bandages, which had been kept applied during twenty-six weeks, had,
amongst other things, been tried. The parents finally had ceased to seek medical
aid, and for some months the disease had been left to itself. At this time the
child came under Dr. Cohn's care. The affected knee was an inch and a half
larger in circumference than the other one, the bones felt thickened, the subcuta-
neous tissue was infiltrated, and the borders of the patella were difficult to make
out. No effusion into the joint was discovered. Passive movements were very
limited and painful, and the tenderness on pressure was considerable. The
general condition of the child was otherwise satisfactory.
The treatment was commenced by applying the bandage only for a few minutes,
but, after four or five days, it could be borne for an hour daily, and sometimes
longer. Occasionally the application was made twice daily, when it was allowed
to remain half to three-quarters of an hour each time. After this had been prac-
tised during a period of three weeks, it Avas found that the difference in size of
the two joints was reduced from four centimetres, or an inch and a half, down to
half a centimetre. The condyles had become restored to their normal form, the
patella had become loose and movable, the pain and tenderness had completely
disappeared, the amount of passive motion was increased, and there was no pain
on movement.
Forcible extension was now practised under chloroform, and was attended by
a recurrence of the inflammation ; but this was rapidly subdued by a continuance
of the previous treatment. The final result was almost perfect cure ; the little
patient could walk and move the joint in all directions without pain ; and the
only trace of the previous disease which remained was a trifling amount of swell-
ing and a somewhat impaired mobility of the joint.
Dr. Cohn meets some of the objections which may be urged. First, as to the
vaso-motor paralysis which follows the use of Esmarch's bandage, and the conse-
quent surcharging of the capillaries after its removal, he is inclined to doubt that
this is anything more than a mere temporary condition. Another objection, that
the capillaries in the inflamed area are not really emptied, he considers cannot
probably be denied, but thinks the property of diffusion of fluids practically
answers the same purpose. Dr. Cohn gives some details as to the mode of appli-
cation of the bandage, the necessity for the limb being thoroughly emptied of
blood, and the occlusion a perfect one ; also that the final constriction should be
made with several turns of the bandage superimposed, rather than with a narrow
rope or tube, as this causes less injury, and is more readily borne. For adults the
breadth should be four centimetres (an inch and a half), and for children from
two and a half to three. How long, he asks, can this bloodless state be main-
tained ? The limit of safety is not likely, he thinks, ever to be reached, and we
need not be anxious on this score, if the shutting out of the circulation be perfect.
An imperfect occlusion is dangerous. The blood passes by the arteries into the
limb, while the venous outlets are completely stopped. The pain is a gr-eat diffi-
culty in this method of treatment, but it may be reduced considerably by not
applying the bandage constricting the limb above tighter than is absolutely neces-
sary, remembering always that the tendency is to apply it too tightly. Further
experience must determine how often the constriction may be repeated, and
whether it should be continued on each occasion as long as possible, or for shorter
periods at shorter intervals.
The author, in conclusion, begs for a trial of his suggested method ; and cer-
tainly the results obtained, especially in the third of his cases, would appear to
justify an affirmative answer to his request. — London Med. Record, Dec. 15, 187 7.
1878.]
Surgery.
565
Pathogenesis of Genu Valgum.
In a paper recently read before the Societe de Chirurgie in Paris (Z' Union
MSdicale) , M. Verneuil rejects the theories of the muscular and ligamentous
origin of genu valgum, which do not appear well founded. While admitting that
there is still considerable obscurity about the question, he adopts the osseous
theory, basing his conclusions upon personal observation. This is the view held
by many distinguished authors, who only differ in assigning the deformity, some
to hypertrophy of the internal condyle, others to atrophy of the external.
M. Verneuil is disposed to accept the doctrine of the deformity being caused
by hypertrophy of the internal condyle of the femur, as put forward by MM.
Oilier and Tripier, who attribute genu valgum to abnormal activity of the epiphy-
sary cartilage of the lower end of the femur. These authors, experimenting on
animals, have been able at will to provoke hypertrophy of the internal condyle
by exciting the internal half of the epiphysary cartilage, and of the external con-
dyle, by irritation of the external half.
Although M. Verneuil has not had an opportunity of verifying clinically M.
Oilier' s theory concerning the two halves of the cartilage,, he has, however, been
able to observe some facts for himself, which confirm in a general way the princi-
ple upon which it is based. — Lond. Med. Record, Jan. 15, 1878.
Curious Case of Ulceration of the Internal Carotid.
At the Petersburg Medical Society (Petersburg Med. Woch., Dec. 29) Dr.
Erichsen related a case of hemorrhage, which he regarded as unique. A
peasant, eighteen years of age, and otherwise robust, was admitted into the
Marien Hospital for a phlegmonous angina of two days' duration. On the second
day after his admission an abscess in the throat broke, discharging normal pus,
and giving complete relief. On the sixth day a slight bleeding from the abscess
occurred, which was easily arrested by a plug. But twenty-six hours afterwards
arterial hemorrhage appeared, which terminated the patient's life in a few
minutes. At the autopsy, the cavity of the abscess, about the size of an egg,
was found filled with fresh coagula. The wall of the abscess was in contact with
the internal carotid, which was perforated by a circular aperture half a centimetre
in diameter, a funnel-shaped dilatation from within outwards being recognizable
at this point. No part of the wall of the artery in its further course exhibited
any diseased appearance. As the pus was in a normal condition, the cause of
the destruction of so firm a structure as the wall of the carotid in nine days is
involved in obscurity. Dr. Wulff suggested the possibility of a secondary abscess
having formed within the sheath of the vessel ; but the preparation afforded no
proof of this occurrence. — Med. Times and Gaz., Jan. 19, 1878.
Anomalous Case of Fusion of the Radial Artery with the Median Basilic Vein,
simulating an Arterio- Venous Aneurism.
A curious case of this has been communicated to the Surgical Society of Paris
by Dr. Challot, Prof. Agiege of the Faculty of Montpelier ; and a report re-
garding it was made to the Society by Mr. Deleus, Jan. 20, 1878.
The subject of this anomaly was an old man, admitted into the hospital Saint-
Eloi, Montpelier, to be operated on for cataract. The operation was followed by
erysipelas, which speedily terminated fatally. It was observed on the entrance
of the patient into the hospital that there existed a tumour at the bend of the
elbow, which he stated he had always had. An examination showed the principal
566
Progress of the Medical Sciences.
[April
signs of an arterio- venous aneurism — movements of expansion, vibratory tremor,
bellows sound, etc. There were not, however, either general hypertrophy of the
limb, nor any increase of temperature. The autopsy revealed the following con-
dition : In place of the .aneurismal tumour expected to be found, there was a
fusion of the radial artery with the median basilic vein for an extent of five or six
centimetres. — L' Union Mi die ale, Feb. 5, 1878.
Spontaneous Perforation of the Popliteal Artery in a Case of White-swell in g.
Dr. Bard, of Lyons, records an instance of this rare lesion in the Gazette des
Hbpitaux, 1877. The patient was a scrofulous boy, aged 9, who had cold ab-
scesses, and a suppurating white swelling of the right knee. The disease of the
knee was of two years' duration; and, when the patient was admitted to hospital,
consisted of a large tumour covered with cicatrices belonging to fistulous open-
ings. The leg was bent nearly at a right angle ; the muscles were contracted,
and movement Avas painful. During the patient's stay in the hospital, fresh ab-
scesses opened, especially on the posterior part of the joint. Drainage was applied
across a large purulent deposit in the popliteal space ; about thirty days after-
wards, spontaneous hemorrhage occurred, but ceased of itself. Xext day, after
a paroxysm of cough and straining at stool, it returned, and was arrested by the
application of Esmarch's bandage. It did not again recur ; but the child died,
and at the necropsy there was found at the anterior part of the popliteal artery
(where the drainage-tube could not have reached it) a circular opening about one-
twelfth of an inch in diameter ; its edges were dentilated and torn, and pre-
sented no trace of inflammatory or reparative action. — London Med. Record,
Jan. 15, 1878.
Employment of Catgut to arrest Hemorrhage from a Bone.
Dr. Ejedinger (Gazette de Strasburg, No. 9, 1877) having performed am-
putation of a thigh, was troubled with the hemorrhage that proceeded from the
bone. As he was proposing to treat it on Lister's plan, and in the hopes of im-
mediate union, it became necessary to stop the bleeding; direct compression
proved fruitless, though it was continued for some time. At length he bethought
him that catgut is absorbed when introduced in the living tissues, and he imme-
diately cut off several ends which he introduced successively into the bleeding
orifice. The flow of blood ceased at once, and no further difficulty was expe-
rienced. In order to study the manner in which catgut behaves under these cir-
cumstances, Dr. Riedinger amputated the leg of a dog and introduced a Xo. 3
thread into the medullary canal of the fibula. The wound was closed, and healed
by first intention. At the end of fifteen days the dog was killed, and on exami-
nation not the least trace of the catgut could be found. A second and larger doc;
O GO
was subjected to the same operation. This being done the compact substance of
the tibia was perforated with an awl, and a piece of catgut introduced into the
medullary cavity. Immediately reunion followed closing of the wound, and the
animal was killed in three weeks. The wound made by the instrument was con-
tracted, but not the slightest trace of the catgut could be discovered either in it
or in the medullary cavity. — Practitioner, Feb. 1878.
Subcutaneous Fracture of Exostoses.
At a late meeting of the Clinical Society of London (Lancet, Dec. 22, 1877),
Mr. Maunder read notes of, and exhibited two patients whom he had submitted
to a novel method of operation for exostosis — " true subcutaneous treatment by
fracture." The first was a case of exostosis of the femur in a girl fifteen years of
age, admitted into the London Hospital on June 23, 1874. She had for many
1878.]
Surgery.
567
months suffered from pain and discomfort at the back of the left knee, and was
unable to extend the leg fully upon the thigh. When walking she could only get
her toes to the ground. On examination a bulging of the thigh, just aboye the
external condyle, could be seen, and this proved to be caused by a pedunculated
exostosis at the back of the femur on its outer side, just at the junction of the
epiphysis with the shaft. The body of the tumour seemed to press against the
tendon of the biceps and the external popliteal nerve. To relieve pain and enable
her to walk, an attempt was made to dislodge the tumour. Abscission was dis-
countenanced from the risk of suppuration, osteo-myelitis, etc.. and fracture of
the pedicle by violence, without any wound whatever, was preferred to subcuta-
neous division of the pedicle with the saw or chisel. One of three results Mr.
Maunder anticipated might follow this procedure ; necrosis of the fragment and
its extrusion by suppuration, which probably would not take place until all risk
of extension of the suppuration to the femur had been prevented by closing in of
the bone-cells opened by the operation ; or absorption of the body ; or its re-
union, but possibly in such a position as no longer to interfere with the patient's
comfort. On July 8, 1874, the skin being protected by a piece of chamois
leather, Mr. Maunder seized the tumour with a pair of gas-fitter's pliers, and by
a sudden jerk broke the pedicle. Ice was applied for two or three days, some
local tenderness, swelling, and ecchymosis resulting from the operation. In spite
of passive movements reunion occurred, but the body of the tumour occupied a
new position, and caused no further discomfort. The second case was that of a
girl fourteen years of age, admitted into the London Hospital in February, 1877,
with a rather large pedunculated exostosis attached to the inner edge of the tibia,
just beloAv the internal tuberosity. The swelling appeared first two years ago
after a sprain of the right knee. A like operation to that in the first case was
performed, but with a different result. The pain and inability to walk have been
removed, but the tumour has not reunited to the shaft of the bone ; and its mo-
bility can readily be recognized.
Subcoracoid Dislocation of the Humerus by Muscular Contraction.
Dr. G. Lappoxi relates, in the Rivista Clinica de Bologna, Jan. 10, 1877,
the following case : —
The subject was a girl aged 15, who had some years preAriously suffered from
chronic inflammation of the right radio-carpal articulation, and afterwards from
some not well-defined inflammation of the shoulder-joint of the same side, as well
as scrofulous ulcers of one leg. Of these affections she no longer presented any
traces : her body was well developed, especially in the bony parts.
One morning in August, soon after rising from bed, she was sitting near an
article of furniture about 3^- feet high, on which she rested her right arm horizon-
tally, with the elbow bent and the hand hanging over the edge. She sneezed
violently twice ; and, without having made any other movement, she was seized
with severe pain in the right shoulder-joint ; at the same time, her arm was raised
from the surface on which it was lying, and then fell useless. There was no
numbness of the hand or arm ; motor power remained intact in the fingers, but
all attempts to move the upper part of the arm produced much pain.
On examination, the head of the humerus was found lying beneath the coracoid
process. Reduction was effected by making extension on the forearm and rotat-
ing the limb outwards, while the head of the humerus was guided by manipula-
tion into the glenoid cavity.
Dr. Lapponi supposes that the dislocation was due to an exaggerated action of
the great pectoral muscle ; and that the contraction of the deltoid, when the arm
was observed to be raised, completed the displacement. — London Med. Record,
Feb. 15, 1878.
568
Progress of the Medical Sciences.
[April
OPHTHALMOLOGY AND OTOLOGY.
Migraine of the Eye.
Dr. Galezowski records (Lancet, Jan. 19, 1878) the following brief notes on
this affection.
There exist a certain number of ocular affections in which no lesions are to be
found, and which might lead one to suspect the existence of some serious malady.
Migraine of the eye, or periodic hemiopia, is marked by very characteristic
visual derangements, which it is of great importance to recognize, so that they
may not be confounded with serious cerebral or other affections. Migraine of the
eye is not so rare as one might suppose, and I have collected observations on
twenty-one cases of this complaint.
The symptoms which characterize this affection are as follows : —
1. The complaint generally attacks those who have for several years been sub-
ject to ordinary migraine ; this latter ceases and is replaced by visual nervous
symptoms, which, however, may come on without being preceded by any other
nervous symptoms.
2. Migraine of the eye is more frequent in females than males, and occurs at
all ages, but I have only twice seen it in individuals as young as thirteen or
fourteen.
3. The onset of the attack is not always the same. In some cases the ocular
migraine is preceded by headache ; while in others, and these are more frequent,
the visual trouble comes on quite suddenly, and is characterized either by hemiopia
or central scotoma.
4. The hemiopia is either monocular or binocular. The former is sometimes
lateral, and at other times it occupies the upper half of the visual field. In the
binocular form the field of vision is obscured laterally, either in the right or left
half of both eyes ; the sight is completely lost in the half of the field of vision ;
nevertheless the acuity of vision remains almost normal. The hemiopia is only
temporary, lasting from twenty to fifty minutes, and then disappearing completely.
Sometimes, however, I have seen it pass into complete blindness, lasting for a
brief period ; or, again, in other cases it is followed by a slight indistinctness of
vision for the remainder of the day.
5. Central scotoma is more rarely the chief symptom of the malady, which
maintains this form throughout ; but three times I have seen it transformed into
hemiopia.
6. Flashes of light, and rainbow colours in zigzag forms, generally accompany
ocular migraine. These phenomena are perceived by the patient in the obscured
part of the visual field, becoming gradually more and more indistinct, and finally
disappearing altogether. Three of my patients said they observed thousands of
luminous musca? and silvery spangles darting about in the darkened field of vision.
7. There may be more or less violent attacks of vomiting preceding or ac-
companying the migraine of the eye, but these are frequently altogether absent.
8. After the disappearance of all the ocular symptoms, giddiness, more or less
intense, comes on, and continues some hours or even days.
9. The scintillating hemiopia is almost always followed by a headache, which
continues all the rest of the day, either in one-half or over the whole of the head.
10. The eyeball is often painful and tender, the patient experiencing a sen-
sation of weight and tension at the back of the orbit, and occasionally the eye is
red and watery.
11. Periodic hemiopia generally recurs at long intervals, once or twice a year
only ; but in certain cases it is more frequent, and may recur as often as once a
1878.]
Ophthalmology and Otology.
569
month, once a week, or even sometimes twice or thrice a week. In these latter
cases there supervenes a disturbance of sight and a sort of asthenopia, which is
almost permanent, and renders all work impossible.
12. Ocular migraine is often observed in those troubled with dyspepsia, but
this last symptom is not constant ; when it exists it almost always indicates the
presence of gout, which, as Trousseau and Charcot have well demonstrated, often
predisposes to migraine.
13. Periodic hemiopia is observed sometimes in pregnant women, but then it
is accompanied neither by scintillations nor by headache. On the contrary, in
pregnant women one sees cerebral troubles characterized by a sort of aphasia and
by encephalopathy, which may continue for half an hour or longer.
14. Analogous cerebral derangements may also be found in migraine of the
eye, but they are relatively rarer and of shorter duration than in the preceding
case.
15. Ocular migraine does not present any gravity, and disappears of itself
under the influence of a tonic strengthening regimen. The sulphate and bromhy-
drate of quinine have seemed to me speedily to relieve the symptoms. The em-
ployment of ferruginous preparations, the cold douche, and avoidance of all ex-
citing aliments, such as coffee, liqueurs, spices, and such like, may also act effi-
caciously in accelerating the cure of migraine of the eye.
Salicylate of Soda in Rheumatic Iritis.
Dr. Galezowski addresses a note to the Academie de Medecine {Bulletin de
V Acad. , Feb. 5th) in which he observes that in rheumatic iritis, accompanied by
plastic exudations and numerous posterior synechia?, every new relapse becomes
dangerous by favouring the obliteration of the pupil. In an eye attacked by this
relapsing iritis there is often much difficulty met with in overcoming the inflam-
matory accidents. In eighteen cases treated by the salicylate he has obtained an
amendment in all the symptoms, and often in three or four days, in the same
patients, who, prior to its employment, used to be under treatment with similar
symptoms for a month or six weeks. What is most remarkable is the immediate
disappearance of the pain and redness, and afterwards the rapid diminution of
plastic exudations. In two cases of irido-choroiditis, or irido-cyclitis, the sali-
cylate arrested very promptly the inflammatory accidents, and immediately sup-
pressed the violent pains which are ordinarily so obstinate as to render iridectomy
obligatory. Excellent results have also been obtained in rheumatic inflammations
of the sclerotic, and especially in ten cases of scleritis and sclero-Jceratitis. In
these, wherein no other treatment gives satisfactory results until after several
months, the salicylate produced an amendment, and even a cure in from one to
six weeks. — Med. Times and Gaz., Feb. 16, 1878.
Acute Glaucoma following a Single Instillation of Atropia.
The following case is recorded by Dr. Hugo Magnus (Zehender's Klin..
Monatsbl., 1876, xiv. p. 386), and the patient was a man aged 72. The atropine
was dropped in to facilitate a proper examination of cataract. The right eye only
was affected, though the drops had been put in both. The patient had been seen
on two occasions before the atropine was used, and there was no occasion to sus-
pect any glaucomatous condition. The symptoms came on within a few hours of
the drops being used. — -Royal London Ophthalmic Hospital Reports, Dec. 187 7..
No. CL April 1878. 37
570
Progress of the Medical Sciences.
[April
Appearance of the Fundus in General Anmmia.
Dr. Hirschberg read a very important paper at the Ophthalmological Con-
gress in 187 7 on the appearance of the fundus oculi in general anaemia, and on
retinitis and atrophy, following loss of blood.
The author stated that E. von J'ager observed in his monograph on the ophthal-
moscope, published in 1876, as well as in a separate communication in 1877, that
it is very seldom that any change can be observed in the central vessels of the
retina in anaemia. He also observed that it is true that it is very difficult to detect
with the ophthalmoscope any changes in the fundus in ana?mia ; and this as the
result both of clinical experience and of numerous experiments on dogs. Even
when these animals were frequently bled until syncope supervened, the retina
exhibited no characteristic appearances. Nevertheless, Dr. Hirschberg found
that in man, in high degrees of anajmia, certain typical changes occur ; but that
these are not in such cases as come under the observation of the ophthalmic sur-
geon. These changes are of three kinds.
1. The papillae of both eyes are pale, although the central vessels retain their
normal size. Later the disk becomes of a shining white, as in atrophy. The
bluish colour of atrophy, however, is not seen, neither is there abnormal sharp-
ness of the disk ; and vision in general remains unaltered, so long as there are no
blood-spots or white exudations on the retina. The normal condition of the disk
returns with convalescence. This affection is observed both in pernicious anamiia
and in ordinary anaemia from loss of blood.
2. In chronic anaemia, whether idiopathic or secondary, the disk becomes
clouded with a whitish haze, and the central reflex streak in the arteries and veins
appears indistinctly, both in the erect and in the inverted image. The blood-
vessels become narrowed, and cannot be followed to any great distance towards
the periphery. In the erect image, the disk is seen to be clouded in slender
radiating streaks, and the vessels to be slightly veiled. As in the former class of
cases, hemorrhages and grayish exudation-spots occur on the retina. The indis-
tinctness of the disk remains during a long time with very slight changes. These
cases often terminate fatally.
3. A few days after exhausting hemorrhage, neuritis occurs, and. without any
appearance of swelling, the papilla becomes spread in various directions at its
edge ; there is considerable cloudiness of the retina, especially towards the peri-
phery, and in the vicinity of the yellow spot, whilst on the whitish background
numerous fresh red blood-spots are seen. There is considerable loss of vision, but
it is not complained of by the apathetic patient, and in a few days absolute amau-
rosis supervenes.— London Med. Record, Eeb. 15, 1878.
Retinitis Pigmentosa without any Pigment visible with the Ophthalmoscope.
Cases of this nature, constituting one of the most curious points in the study of
retinitis pigmentosa, are rare. Such have, however, been recorded by MM.
Galezowski, Lanclolt, and Maurice Pen-in . That which is here related by Prof.
Huidiez (Annales d" Oculistique, Xovember-December, 1877) presented the
same remarkable histological changes as did that of M. Perrin (Annales d' Ocu-
listique, 1875). ' Mdlle. V., aged eight years, had suffered, according to her
parents, from hemeralopia from her earliest infancy. Her grandparents on her
mother's side were first cousins, and a first cousin of her maternal grandmother,
aged fifty-five, whose parents were cousins, had also been afflicted with hemera-
lopia all her life. The little patient was very intelligent ; her hearing and her
pronunciation were also perfect. The visual defect must, therefore, be ascribed
1878.]
Ophthalmology and Otology.
571
to consanguinity in accordance with the opinion of Yon Grafe, and not to idiocy
or to deaf-mutism, as suggested by Liebreich.
The hemeralopia was very marked. The field of vision was considerably nar-
rowed, and to an equal extent in the two eyes. Central vision was good, as also
the perception of colours in the same region ; and she could read No. 3 of
Wecker's metrical types fluently.
With the ophthalmoscope there was a slight haziness of the retina around the
disk, as also around the entire peripheral region. The macula lutea was normal.
There was no trace of pigmentation of the retina whatever.
In all probability the conditions of the retina resembled those recorded in M.
Perrin's case, and which are thus described : * ' The colouring matter had no
existence along the track of the vessels as in the cases of retinitis pigmentosa of
Landolt ; it is. on the contrary, localized in the external granular layers of the
retina. . . . The nerve-fibres are atrophied, but the fibres of Muller are unaf-
fected 5 the ganglionic cells are intact, as are the two layers of granules. Imme-
diately on the outside of these, however, there appear pigmented masses of cells
containing from eight to ten cells in each ; tine molecules of pigment are here and
there lodged in the interior of the granules themselves." In no portion of the
retina was any pigment found in the neighbourhood of the vessels, so that its
presence elsewhere could not be ascertained by the ophthalmoscope, hidden as it
was too by the infiltration of the anterior layers.
In the present instance, the diminution of the field of vision indicated that the
pigmentation, assuming its existence, was extensive. The deposit does not in
these cases, as in the typical forms of the affection, assume the stellate appearance
which is, in fact, due to the ramification of the bloodvessels with their sheaths ;
for as yet its appearance has only been described amongst the external layers of
the retina which have no bloodvessels. The colouring matter appears to be de-
rived from the choroidal epithelium, and is absorbed by the rods and cones and
by the external granules, all of which become blended together, and form irregular
masses in which the pigmentation is well marked, but not radiating or stellate in
its arrangement. — London Med. Record, Feb. 15, 1878.
Retinal Aneurism.
Two instances of this rare affection are very briefly related in the last number of
L'Anne'c Medicale, the monthly journal of the Medical Society of Caen and Cal-
vados. Dr. Briere, of Havre, who relates the cases, points out their analogy
with the miliary aneurisms of the brain, with which the researches of French
observers (especially M. Liom-ille) were the first to make us acquainted. He
refers also to a case of retinal arterio- venous aneurism described by Magnus Hugo
in Yirchow's Archiv in 1874. The first case described was seen by Dr. Briere
two years ago. It was in a well-built, muscular man, forty years of age, who
experienced great pain in the left eye during defecation, followed by disturbance
of vision in that eye. The eye was examined ophthalmoscopically by Dr. Briere
three hours afterwards, and he found a spherical tumour, the size of a pin's head,
attached to one of the secondary divisions of the central artery. He observed
also a slight expansile pulsation of the tumour synchronous with the temporal
pulse. Xo change was noticed a fortnight later. The patient then left Havre,
and his subsequent history could not be traced. The second case occurred in a
female seventy-three years of age, the subject of chronic bronchitis, and suffering
from violent paroxysms of coughing. In June, 1877, she first noticed some visual
disorder ; objects were ill-defined, and appeared distorted. On examination of
the fundus of the left eye, an ampullary dilatation of one of the arterial twigs to
the other side of the disk was observed. This fusiform aneurism appeared to
572
Pkogress of the Medical Sciences.
[April
measure two millimetres and a half in breadth and four millimetres in length. It
had determined a central scotoma. Beyond this lesion, which would probably
terminate in rupture and hemorrhage, the fundus was normal. — Lancet, Feb. 23,
1878.
Treatment of Paralysis of the Muscles of the Eye.
The Klinische Monatsh latter fur Augenheilkunde for November contains a short
communication from Professor J. Michel on the treatment of paralysis of the mus-
cles of the eyeball by gentle traction. His treatment, which was successful in a
recent but total paralysis of the abducens of rheumatic origin, consists in taking
hold of the insertion of the affected muscle with a pair of fixing forceps, and gently
drawing the eyeball as far as possible in the direction in which the muscle would
move it ; afterwards bringing it back to its former position. This manoeuvre is
repeated backwards and forwards for about two minutes every day. The author
states that the manipulation is attended by but little pain, and that the slight in-
flammation set up in the conjunctiva is easily combated by cold applications.
After each sitting a slight amelioration was observed. Immediately after the
sitting, the muscle was found to be capable of contracting to the extent of a line
and a half to two lines. This power was less after an hour, but was still percep-
tible. He states that recovery was perfect after five weeks of this treatment. —
London Medical Record, Dec. 15, 1877.
Binocular Accommodation.
The additional part of Zehender's Monatsblatter, for July, consists of an in-
augural dissertation on this subject by Dr. Theodore Rumpf, read before the
medical faculty of Heidelberg. This is a work of the highest physiological in-
terest, as well as of extreme practical importance to the ophthalmologist. The
author shows, by a series of the most careful experiments, that the accommodation
of the two eyes is always equal both in emmetropia and in ametropia, except, as
has been shown by Werth, where the faculty of binocular vision is absent, as in
strabismus from considerable defect of one eye. This fact is easily demonstrated,
m the case in which the two eyes have equal refractive power, by placing a printed
page on one side of the visual field so that it is nearer to one eye than to the
other. It will then be found that only the eye which is nearest is accommodated
to the distance of the page ; by covering this eye, the page will be seen out of
focus. He explains the fact that Schneller and AVomow arrived at a different
conclusion, by their not having eliminated the effect of astigmatism. Indeed, in
repeating their experiments, he arrived at a negative result. His measurements
were all effected with a fine double wire, so that only one meridian of the cornea
was used; thus completely eliminating the error of astigmatism. — London Med-
ical Record, Dec. 15, 1877.
Therapeutic Use of Electricity in Ophthalmology.
A. Bergh (Hygiea, 1877, and Nordiskt Medicin. Arkiv, Band ix., Haft 4)
has, during the last ten years, used electricity in the treatment of paralysis of the
ocular muscles, arising from peripheric causes ; of muscular asthenopia incapable
of treatment by glasses or by operation ; of blepharospasmus resulting from neu-
rosis of the trigeminal nerve ; and also, in recent years, of amblyopia. In the
muscular affections he generally used the induction-current, in the nervous the
constant current, exclusively. For stimulation of the retina, the most evident
sign of which is the manifestation of phosphene, the most adA antageous plan is to
apply one electrode to the nape of the neck, and the other on or near the eye.
1878.]
Midwifery and Gynecology.
573
Bv changing the direction of the current the circuit remaining closed, a more
powerful irritation is produced than when the circuit is simply closed or opened,
as Brenner has shown. A weak current should be used, and the remedy must be
applied daily. The author has obtained much better results from the simultaneous
use of electricity and injections of strychnia than from the latter alone. In speak-
ing of hemiopia, Bergh denies that the inner or outer field of vision of one eye
can be defective while that of the other is normal, just as both middle halves can
be defective while the lateral ones perform their functions, provided that optic
neuritis be not present. He appears also to doubt the reality of the so-called
amhhjopia exanopsia. The author naturally seeks in the first place the remote
causes of amblyopia, if such can be discovered. But even in this, as in all cases
when the cause of the malady remains obscure, experience has shown that the
use of electricity and of strychnia, either alone or together, produces very favour-
able results. The prognosis, however, must always be made cautiously.
All the cases of idiopathic hemeralopia which came under treatment were cured
in a very short time by electricity and strychnia. In congenital amblyopia no
result was obtained. From January 1, 1874, to March 31, 187 7, the author was
consulted in fifty-nine cases of amblyopia, not including congenital. Of these,
fifteen were treated with electricity and strychnia, four with electricity, and in all
these cases improvement was produced. Two cases did not come under treat-
ment. The remaining 38 were treated with strychnia alone ; of these, 23 were
not again heard of ; three were improved, and 12 remained uncured.
Brief histories of 19 cases are given, showing the rapidly successful treatment
of cases of advanced amblyopia, hemiopia, and recent traumatic amblyopia.
In peripheral paralysis of the ocular muscles, the anode is applied in front of
the ear, and the cathode, which is small, and has a rounded end, covered with
linen and moistened to the muscles, either directly to the eye itself or through
the closed eyelid. In mydriasis the cathode is held to the centre of the cornea,
so as not to irritate the dilator muscle of the pupil. instead of the sphincter. At
the same time, however, eserin is dropped into the eye.
In muscular asthenopia the electricity is either applied to each eye separatelv,
or to both internal recti at the same time. In blepharospasms the anode is
carried round the eye, while the cathode is placed by turns over the branches of
the fifth nerve surrounding the eye. — London Medical Record, Jan. 15, 1878.
MIDWIFERY AXD GYX.FCOLOGY.
Dislocation of the Xiphoid Cartilage during Pregnancy.
M. Polaillox relates in the Union Medicale (Xo. 24 for 187 7) the case of a
woman aged 35, a primipara. who, in order to hide her pregnancy, wore a nar-
row corset up to the seventh month, when she was one day seized with pain in the
epigastrium, which was so violent that she was obliged to remove the corset.
From this time, the patient perceived a small movable body at the painful part.
The pain returned whenever the part was touched ; also during eating and diges-
tion. It returned during labour, which was completed with the aid of the forceps.
Careful examination of the painful part showed that the xiphoid process was dis-
located with its base inwards, the apex causing a projection of the skin. It was
very movable ; but movement caused severe pain. An attempt at replacement
was unsuccessful. After a rather long stay in bed, the mobility and tenderness
574 Progress of the Medical Sciences. [April
had diminished. At the end of three months, the xiphoid process was almost
fixed in its normal position; the part was no longer painful when' touched, and
the pain during- digestion had disappeared. — British Med. Joum., Dec. 8, 1877.
Normal Labour during Extra-Uterine Pregnancy.
In the Journal de Medecine, Not. 187 7. M. Labutut reports the following
case. A woman had had a previous normal labour, and tAvo years later, had all
the signs of pregnancy. At the end of five months, after progressive development
of the abdomen, she had violent pains, but without result. After their cessation,
she was sick for six months. Menstruation then reappeared, and the patient
enjoyed tolerable health. The tumour subsided, the pains disappeared. Five
years later, the catamenia were again suppressed. After several months, she was
examined by a midwife of Toulon, Madame R ampin, who diagnosed pregnancy
at the ninth month. She detected also a voluminous tumour in the right side,
which, after hearing the patient's history, she attributed to an extra-uterine preg-
nancy. Fifteen days after this, the patient was naturally delivered of a living
child. She lived two years, and died at Toulon Hospital, of pulmonary tubercu-
losis. At the necropsy, there was found in the right Fallopian tube a foetus at
term, macerated, and enveloped in a thick pouch. The case was then one of tubal
pregnancy, dating back five years. Notwithstanding this, there had been normal
conception and delivery. — Lond. Med. Record, Feb. 15, 1878.
Ano-Pelvic Version.
In the Bulletin de V AcadSmie de Medecine. Oct. 2, 1877, is an account of a
new method of version to which M. GufexiOT resorts in cases of difficult trunk-
presentation, complicated with uterine tetanus, where derotomy and evisceration
of the foetus have been recog-nized as useless. The process of ano-pelvic version
consists in using- the weight of the patient's body to introduce the hand without
fatigue towards the fundus uteri ; in using- the pubie arch, or the sacro-coccvgeal
hollow, as the point d'appui for turning the foetus with the aid of the finger curved
like a crotchet in the rectum; and, as regards the rest of the manoeuvre, in fol-
lowing-the ordinary rules of podalic version. The advantages M Git&niot claims
for this procedure are : 1. The pelvis is generally easier to find than the feet; 2.
The hold afforded by the pubic arch or sacral hollow is firm and not likely to
slip; 3. The traction being- direct, the force is economized ; 4. The evolution of
the foetus can be effected whether the traction is towards the dorsal or the abdo-
minal aspect of the foetus; 5. When podalic version has failed, the ano-pelvie
process permits version to be accomplished. — Lond. Med. Record, Jan. 15, 1878.
On the Treatment of Post-partum Hemorrhage by the Injection of Hot Water
into the liter xi s.
In an interesting paper on this subject, Dr. Lombe Atthill, Master of the
Rotunda Hospital, Dublin (Dublin Journal of Medical Science, Jan. 1878),
says that, without doubt, the most efficient means at our command for the arrest
of flooding after labour is the injection of a styptic, such as the solution of the
perchloride of iron into the uterus. This is a procedure which, after repeated
trials, he has no hesitation in recommending, and shall continue to have recourse
to it in suitable cases. Apart, however, from the alleged danger of injecting a
powerful styptic into the uterus — a danger which, though well-nigh groundless,
suffices to deter many from having- recourse to it — there is this objection to the
practice, that the perchloride may not always be at hand when the emergency
arises, and that valuable time may be lost ere it can be obtained.
1878.]
Midwifery and Gynaecology.
575
The introduction of the hand into the uterus — in some cases an efficient method
of checking postpartum hemorrhage — is certainly not free from danger, and is,
moreover, by no means reliable in its results. While the routine treatment by
cold, whether applied to the surface or injected into the uterus, requires for its
success that the patient be possessed of sufficient vital energy to insure reaction.
In other words, the application of cold in post-partum hemorrhage is a most effi-
cient remedy in cases where a sudden loss of blood occurs in an otherwise healthy
woman, who lias not been exhausted by an unduly prolonged labour ; but is alto-
gether unreliable, and in many cases positively injurious, where the patient has
been debilitated by previous disease, worn out by long protracted suffering, or
exhausted by frequent, though it may be small, losses of blood.
As far as Dr. A.'s personal experience goes, those apparently alarming losses of
blood which sometimes occur immediately after the birth of the child, or expul-
sion of the placenta, are not likely to terminate fatally ; they can in general be at
once arrested by steady pressure over the fundus of the uterus, and by the use of
cold, but the hemorrhage to be dreaded is that in which the blood trickles away
in a little never-ceasing stream, the uterus relaxing and contracting alternately.
This form of hemorrhage, of which he has seen several fatal cases, is most liable
to occur in debilitated women, and, in such cases, cold is in general absolutely
useless — nay, more, often injurious.
Dr. Atthill's experience in two cases show that the injection of hot water pow-
erfully stimulates the uterus to contract, and thus rapidly checks the hemor-
rhage, and evidently acts as a stimulant. The effect on the pulse was most
marked, indeed the pulse was affected more rapidly than by the hypodermic in-
jection of ether, and it did not flag again. The faces of the patients, too, lost
the deadly hue they previously had worn — and last, not least, they expressed
themselves as having experienced the greatest relief, and obtained great comfort.
Dr. Atthill believes that in hot water we have at once a safe and efficient
remedy, one comforting and agreeable to the patient, and an agent which is
always at hand. Whether it is as reliable as the perchloride of iron remains yet
to be proved. As the advantage to be derived from its use is not limited to cases
of post-partum hemorrhage, its range of usefulness is great.
In a subsequent communication to the Lancet (Feb. 9, 1878), Dr. Atthill
states that this mode of treatment has been carried out in all suitable cases occur-
ring in the hospital, and in the extern maternity, in connection with it, and gives
the notes of these cases,^ sixteen in number.
In conclusion, he adds : 1st. That he does not, as a rule, employ hot water
in cases of post-partum hemorrhage till the application of cold has failed to arrest
it. 2d. That it is most markedly beneficial in the case of weakly, delicate women,
and in those in whom, profuse hemorrhage having been checked, blood continues
to be lost in small quantities, the uterus alternately relaxing and contracting. 3d.
That, for its successful application, the tube of the syringe must be carried fairly
into the uterus. 4th. That the temperature of the water must not be under 110°,
and that it may safely be used at 1 1 5°.
In no single instance did any unpleasant symptom follow; and all the patients,
with the exception of one, stated that they experienced feelings of the greatest
comfort and relief from the treatment. In the case referred to, in which pain
followed the injection of the hot water, it was uncertain whether the ovum had been
expelled or not. Dr. Atthill had but once previously injected hot water in a case of
abortion, but this woman was in a very critical state ; she was cold and faint, and he
stated to the class that if the ovum had not come away the hot water might stimu-
late the uterus to expel it, and that if the uterus were empty he believed it would
arrest the draining which still continued. This case is, in his opinion, a very im-
57G Progress of the Medical Sciences. [April
portant one, and will lead him for the future to treat hemorrhage occurring in
cases of abortion in a similar manner. t
[Abstracts of interesting papers, by Dr. Windelband and Dr. Runge, on the
use of hot- water injections in uterine hemorrhage, will be found in the numbers
of the ' American Journal of the Medical Sciences for October, 1876, p. 589, and
October, 1877, p. 588.]
Prophylaxis of Puerperal Fever.
The Berliner Klinische Wbchenschrift for January 7 contains an article by
Dr. Zweifel on the advantages of the antiseptic treatment as a preventive of
puerperal fever. He mentions BischofF as the first who adopted Lister's treats
ment in child-bed. BischofF' s plan is to give a bath at the commencement of
labour-pains, and to wash out the vagina Avith a 2 per cent, solution of carbolic-
acid. This injection is repeated every two hours. The attendant's hands are
disinfected in a 3 per cent, carbolic solution before each examination. In place
of the time-honoured lard, a 10 per cent, carbolized oil is used. When it is
necessary to pass the hand into the uterus, its cavity is also washed out with a
2 or 3 per cent, carbolic solution. After delivery, any little rent or wound is
dressed with one-tenth carbolic solution. A pad of cotton- wool, dipped in 10 per
cent, carbolized oil, is placed at the vulva. During the first thirteen days the
lying-in woman, whether sick or not, has frequent vaginal and uterine injections
of carbolic solution. This treatment has been successful in the hands of BischofF ;
but, like that of Schucking, which consists in a permanent uterine irrigation, it is
too strict and minute. By the employment of a modified antiseptic treatment,
Dr. Zweifel has confined 184 women at his lying-in hospital without a death.
Several had febrile symptoms, which disappeared under the Lister treatment.
Dr. Spiegelberg has only lost 5 mothers in 900 labours, by taking- similar anti-
septic precautions,
[It must not be forgotten that Professor Tarnier has obtained equally satisfac-
tory results in his pavilion at the Paris Maternity by care and cleanliness alone,
unaided by carbolic acid.] — London Med. Record, Feb. 15, 1878-
Digitalis in Metrorrhagia.
Amongst the medicines having the power of controlling congestive metrorrha-
gia, M. Desxos {Journal de Medecine et de Chirurgie Pratiques) strongly
recommends digitalis, which may be successful even where ergot has not yielded
good results. The digitalis is given in the form of an infusion, in doses of from
50 to 60 centigrammes (7|to 9 grains) in 150 grammes (about 5 ounces) of water.
It acts in these cases by slackening the circulation. M. Desnos reports, amongst
other cases, one of a young woman, in whom a metrorrhagia of several days'
duration could not be arrested by a great variety of means successively employed.
Digitalis administered in the manner indicated above almost immediately induced
stoppage of the hemorrhage. — Lond. Med. Record, Jan. 15, 1878.
Report of a Fifth Series of Fifty Cases of Ovariotomy.
Dr. Thomas Keith, Surgeon for Ovarian Diseases to the II oval Infirmary,
Edinburgh, has again recorded {British Med. Journal, Jan. 5, 1878) a diminish-
ing mortality after ovariotomy. In the first series of fifty cases, there were 11
deaths ; in the second, 8 ; in the third, 8 ; in the fourth, 6 ; in the fifth, 4. Of
the four fatal cases, two died comatose, with suppression of urine, within thirty
hours after operation ; two died from blood-poison. One was a case of tumour
of 53 lbs., complicated by a large fibroid uterus. Dr. K. unwisely removed a
1878.1
Midwifery and Gynaecology.
577
pedicellated portion of the fibroid, which seemed to be much in the way. A
drainage-tube was put in behind the tumour in the pelvis. The tube was dis-
placed, probably as the patient was moved into bed. ~No serum escaped by it ;
and a fatal result happened in a case that promised to do well. Dr. Keith has no
hesitation in saying that earlier operation would have saved the other three, for they
were originally healthy women. One was a large sarcoma of slow growth. When
seen, the patient had been little out of bed for sixteen months. The tumour was
removed quite easily ; but extensive adhesions to the mesentery and intestine led
to the tying of nearly a hundred vessels. In the third, also complicated by a
large uterine tumour, an inflammatory affection of the knee prevented the patient
from coming to town when she was prepared to do so six months before. During
this time she was tapped six times, seven gallons of fluid being removed on each
occasion. The cyst- walls alone weighed upwards of 50 lbs. ; adhesions were uni-
versal, and of the utmost firmness, especially to the liver. The fourth fatal case
— one of double dermoid cyst — had been often urged by Dr. Mackenzie, of Lark-
hall, to have the tumour removed in a favourable time. An injury caused rup-
ture of the cyst, and for nine months she was confined to bed. For long she was
blood-poisoned, and had double phlegmasia clolens, the oedema extending even
into the axilla ; yet she rallied after many tappings. The operation lasted three
hours and a half. Masses of fat and hair had escaped into the upper part of the
abdomen, and had become encysted by thick deposits of lymph in a most wonder-
ful way. All this had to be dissected out. When she was placed in bed after
operation, the temperature had fallen to 92 cleg.
Not included in the table is that of a case in which ovariotomy was performed
a second time. The patient recovered. In two cases of acute suppurating der-
moid cysts — one seen with Dr. Keiller, the other in Lanarkshire with Dr. Lind-
say and Dr. Lennox, of Hamilton — the pelvic adhesions were such that relief by
ovariotomy could not be thought of ; yet as both were in the last stage of the dis-
ease, it seemed right to try something. They were treated by incision and drain-
age, and both recovered perfectly. A third, similarly treated nearly two months
ago, so far promises well in the hands of Dr. J. Cox, of Innerleithen. Two cases
of cyst of the broad ligament are apparently cured by tapping.
In three cases Dr. K. was unable to complete the operation. One, aged 67, a
patient of Dr. Lorraine, had been often tapped. On exposing the tumour, it was
found to be malignant, with disease of the peritoneum. There was no ascites ;
the tumour was not disturbed. The second was sent by Dr. William Bell.
Ascitic fluid surrounded a papillomatous growth. Early operation was advised,
in the hope that no secondary affection of the peritoneum had yet taken place.
The pelvis was filled with secondary growth, involving the base of the tumour,
and he was unable to remove the pelvic portion. The third came from Dr. Borth-
wick, of Dumfries. A large thin-walled cyst was so adherent that, though part
of it was separated, the pelvic portion could not be removed. The cyst was fixed
in the wound and drained. These three cases ultimately proved fatal.
As in former reports, every case is now given in which Dr. K. has interfered
with any abdominal tumour except by tapping. In the first hundred cases (Lan-
cet, 1867 and 1870), deaths after incomplete operations were included amongst
the deaths of the completed cases. A short history was also given of every case
of ovarian tumour that was seen and not operated on, as well as the reason for
not operating. A sort of balance-sheet was thus formed, by which the value of
the operative results might be judged. In the second hundred cases, the London
example was followed, and the deaths after completed and incompleted operations
were separated ; but details were given of every case of incomplete operation.
578
Progress of the Medical Sciences.
[April
Now, the practice seems to be to ignore altogether incomplete operations, explo-
ratory incisions, or errors of diagnosis.
Dr. K.'s confidence in the cautery in the treatment of the pedicle was some
time ago shaken by hearing of a death from hemorrhage the day after operation
in a case where it was employed. In four-fifths of the cases in this series the
clamp was used, the cautery being reserved for very short pedicles. Of late, his
faith in the cautery has returned, and he has used it in some ordinary operations.
The last twenty-one operations were performed under the carbolic acid spray.
Sulphuric ether has now been given in two hundred operations. Properly ad-
ministered, it is nearly a perfect anaesthetic. Dr. K. has pleasure in acknow-
ledging the value of Mr. Ormsby's simple inhaler.
MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Successful Treatment of Opium Poisoning hy Atrojria.
The practical application of our acquaintance with physiological antagonisms
was well illustrated at the West London Hospital on the 14th inst. A woman
living at a public house not far from the hospital took from twelve to seventeen
grains of opium, as closely as could be ascertained, at eleven o'clock in the fore-
noon. On the patient being brought to the hospital at 11.30, an emetic was ad-
ministered ; vomiting followed ; and the ordinary peripatetic treatment was then
commenced. At 2 P. M. the respiration was failing, and the pulse was weak and
small. At this time the case was seen by Dr. Milner Fothergill, who ad-
vised the subcutaneous injections of one grain of sulphate of atropia, to arrest the
failure of respiration that seemed imminent. This was done at 2.15 P. M. For
the next ten minutes the respiration fell till it became imperceptible. The patient
was now put into a warm bed, as she was very cold from having been walked
about. Ten minutes later the breathing began to return in shallow respirations,
about five in the minute, with a long sigh at intervals. Improvement steadily
continued till, at 4.30 P. M., the patient was breathing thirteen in the minute,
the respirations being deep and long. At this time the temperature was only
97.5°, an indication of how low it had fallen. At 8.30 P. M. the respirations
were 24, the temperature 100.4°, and the pulse 128, full, but compressible. The
patient passed a slightly restless night ; and at 10 A. M. of the loth the respira-
tions were 18, the pulse 100, and the temperature 99.8°. The pupils were slightly
dilated. The patient was thirsty, but did not complain of much dryness of the
throat. In the afternoon she was in all respects well and rational. No symp-
toms of belladonna-poisoning were exhibited, though the amount of atropine in-
jected was large. The history of this case suggests that in similar but less suc-
cessful cases the atropine has been given in too small quantities. So far as we
know, this is the first time that a fatal dose, or what is commonly believed to be
a fatal dose, of one poison has been given at once to check the lethal action of
another poison. The result of the case ought to materially influence the future
treatment of opium-poisoning. — Med. Times and Gaz., Feb. 23, 1878.
1878.]
579
AMERICAN INTELLIGENCE.
ORIGINAL COMMUNICATIONS.
A Tasteless Antiperiodic. By Samuel Ashhurst, M.D., of Phila-
delphia.
The ever-growing demand for antiperiodics, with the consequent ad-
vance in the cost of quinia, is leading to a rigid scrutiny into the merits
and efficiency of the other and cheaper alkaloids derived from Peruvian
Lark. It has been well known for years, and extended experiments have
proved, that all the alkaloids thus derived, possess in greater or less degree
the same properties,- while the advanced chemical skill bestowed upon
their manufacture has resulted in proving that the difference in power
and efficiency between them is not so marked as was at one time supposed.
Cinchonia has been recognized by the profession, for a long time, as an
efficient antiperiodic and tonic, but when prescribed it has very generally
been in the form of a sulphate, its conversion into a salt having been
thought imperative on account of the great insolubility of the neutral alka-
loid. In the form of a sulphate it was used by the late Dr. William
Pepper, and the results he obtained were recorded in this Journal so far
back as 1853.
It is, however, this very insolubility of the base cinchonia, in the mouth,
which has induced me to make use of it in the case of children, and of
those persons who, while they think they cannot take a pill, at the same
time dread the intense bitterness of a solution. It is a matter of easy
proof that the insolubility of cinchonia, like that of many other substances,
does not persist when subjected to the action of the acid gastric fluids,
and that its solution is speedily accomplished in their presence.
There is, however, an inherent difficulty in administering the powder
pure, and this is its tendency, like many other insoluble powders, to be
retained in the mouth by adhering to the teeth. These remains of the
dose, being gradually dissolved by the continued action of the salivary
fluid, the bitterness, common to all the cinchona alkaloids, is fully devel-
oped. This difficulty can in great measure be overcome, by mixing the
cinchonia with various substances, which, while they increase the bulk of
the powder, fully compensate for this disadvantage by facilitating its com-
plete passage through the mouth. Every physician will of course consult
his own taste and pharmaceutical skill in the choice of a diluent. I Lave
found sugar of milk to answer the purpose very well. As a further guard
580
American Intelligence.
[April
against the solution of the cinchonia a small quantity of bicarbonate of
sodium may be added with the object of neutralizing any free acid that
may be present in the saliva. A powder containing one grain of cincho-
nia, four grains of sugar of milk, and one-tenth of a grain of bicarbonate
of sodium, possesses only the slightly sweet taste of the sugar of milk, and
is quite readily miscible with water or milk, or, if preferred, can be easily
swallowed dry. With the object of promoting the solution of the cincho-
nia in the stomach, I at one time thought it well to administer an acid
drink some little period after the ingestion of the remedy, but I am now
convinced that this precaution is very rarely necessary, and that the gas-
tric juice is quite able ordinarily to perform this task unaided.
My original intention was to have appended some abstracts of cases in the
treatment of which I had made use of cinchonia, but upon second thought I
have concluded that it is not worth while to occupy the space of the Journal,
or the time of its readers, by adducing proofs of the efficiency of Peruvian
bark. Suffice it to say that wherever the use of cinchona products is in-
dicated, the alkaloid cinchonia will be found to fulfil these indications.
As the base cinchonia, in powder, contains no water of crystallization, I
am in the habit of prescribing the same dose of it as of sulphate of quinia.
To conclude : whenever, from any cause, it is desirable to administer an
antiperiodic, or vegetable tonic in powder, I have no hesitation in saving
that the neutral alkaloid cinchonia will be found efficient to a degree but
little, if at all, less than quinia, that it can be so administered as to be
tasteless, and that it is very cheap — less than one-sixth the cost of the
salts of quinia.
These few lines have been written in the hope that others may be in-
duced to give the remedy a fair and thorough trial, and that on account
of its tastelessness they will find it to fill desirably a niche in their list of
medicines.
Ligatures made from the Sinew of the Whale. By T. X. Ishiguro.
First Surgeon, Imperial Japanese Army. Communicated by Samuel D.
Gross, M.D., Professor of Surgery in Jefferson Medical College, Phila.
It is a universally acknowledged fact among us that since the introduc-
tion of the catgut ligature into surgical practice, we have derived much
benefit from its use ; but its costliness, and preparation with carbolic acid,
have made it rathe.' an article of inconvenience, especially for military
purposes.
The new ligature I have recently invented is made of the tendon of the
whale, beaten up into very fine fibres. The mode of manufacturing the
ligature is very simple : it is generally made one metre long, and weighs
about 1.8 decigramme, or 3 grains ; and although it is as fine as an ordi-
nary silk ligature, is capable of sustaining 1940 grammes, or about 4 lbs.
1878.]
Domestic Summary.
581
4 oz. When it is kept in the wound a week or ten days, it is found to be
softened and nearly dissolved.
I have made quite a number of experiments by applying it in the liga-
tion of arteries, and it has proved Very satisfactory.
The ligature may be kept and applied just as that of the ordinary silk
ligature.
The advantages which this new ligature possesses over the catgut are two-
fold, namely: 1st, its cheapness; 2d, its capability of application without
being prepared in carbolic acid.
Being fully convinced that this ligature may prove a valuable article in
surgical practice, I respectfully communicate the fact to the medical pro-
fession at large.
The ligature may be procured of Ichizayemon M. Iwashiya, Honcho
Sanchome, Tokio, Japan.
DOMESTIC SUMMARY.
Perityphlitis and its Treatment.
Dr. Saxds, at a recent meeting of the New York Academy of Medicine
(Med. Record, Jan. 19, 1878), stated that he had had somewhat unusual oppor-
tunities for the study of perityphlitis, and he gave the details of twenty cases of this
disease which had come under his observation, nineteen of which had occurred in
private practice. An analysis of these cases showed the following results : Reso-
lution had occurred in 7 cases ; recovered after operation, 8 ; recovered after
rupture of abscess into bladder, 1 ; recovered after- rupture of abscess into rectum,
1 ; died after abscess had been opened, 1 ; died after an unsuccessful attempt to
reach the abscess, 1 ; died, without operation, of secondary meningitis, 1 .
In reviewing his experience, Dr. Sands remarked that the chances of sponta-
neous recovery by resolution should never be lost sight of, but ought to be care-
fully estimated in every case before deciding the question of operation. He could
recall several instances in which the symptoms, although characteristic, were mild
throughout the entire course of the disease, and never indicated suppuration.
Usually the fortunate result had followed the use of opium, leeches, and fomenta-
tions, which he regarded as the most valuable means of treatment. In these
mild cases, resolution had generally occurred early, at the end of the first or the
second week. Occasionally the symptoms, although acute at the onset, had
quickly subsided under the treatment above mentioned. In rare instances the
disease had run a chronic course without suppuration, one patient having had oft-
repeated attacks during a period of five months, and finally recovering without
the formation of abscess. In these chronic cases benefit seemed to have been
derived from blisters and mercurial inunction. The liability to recurrence after
resolution was an interesting fact. One of the patients, a young lady, he had
seen in consultation with Dr. Draper, had a second attack a year after the first
one, both unaccompanied with suppuration. Another had abscess two years after
the first attack. A third had three attacks during a period of two years, the last
one only terminating in suppuration.
In the case mentioned as having died of secondary meningitis, the abscess,
although large, and dependent on perforation of the vermiform appendix, was
found, post-mortem, in the lumbar region. It was only suspected during life,
and did not reveal itself by the usual tumour in the iliac fossa. In the case in
582
American Intelligence.
[April
which an unsuccessful attempt was made to reach the abscess, the latter was like-
wise situated behind the ascending colon, and was caused by a perforating ulcer
of the posterior wall of the caecum. General peritonitis and tympanites existed
at the time when the exploratory incision was made, and rendered the examina-
tion of the iliac region difficult and unsatisfactory. If, in such cases, an exact
diagnosis could be made, or even if the situation of the abscess could be reason-
ably conjectured, an incision in the lumbar region would be indicated as in the
operation of colotomy.
Dr. Sands had found that, in cases terminating in abscess, the signs of suppu-
ration became manifest between the first and second week of the disease. Fluc-
tuation was generally absent during this period, and the formation of matter was
indicated by the occurrence of chills or sweating, and especially by a continued
elevation of temperature, the thermometer often marking from 101° to 1 <>;,-. In
doubtful cases, he had settled the question by the use of the aspirator. In regard
to the proper time for opening the abscess, he thought that no rule could be laid
down which would apply to all cases, and that the urgency of the symptoms,
as well as the duration of the disease, should be taken into account. Unquestion-
ably, delay was dangerous, and in the only case he had seen which proved fatal
after the abscess had been opened, the latter had attained enormous dimensions,
and was not incised until the tenth week. But, on the other hand, the operation
might be performed too early, before the abscess was ripe, or before it had
approached the surface so as to be accessible. He had once assisted a medical
friend who operated, with his concurrence, on the ninth day, but no matter could
be found, and eleven days elapsed alter the operation before the abscess broke
into the wound. Perhaps no harm had come from any of these early operations,
and it might be urged that they were of service by dividing the resisting aponeu-
rotic and muscular structures that would otherwise have opposed the progress of
matter towards the exterior. Nevertheless, he felt inclined to wait a reasonable
period, because then the matter would be more likely to be reached, and because
time would thus be afforded for the consolidation and adhesion of the tissues over-
lying the abscess, without which the fetid contents of the latter would be apt to
infiltrate the cellular planes, and occasion sloughing. This he had seen in one
instance, and the complication rendered recovery tedious. Of the eight cases
that were treated successfully by incision, Dr. Sands himself had operated in
five, the remaining cases having been seen in consultation. Excepting the one
already referred to, in which the operation was undertaken on the ninth day,
they were all submitted to operation between the twelfth and the eighteenth day.
As to the method of operating, Dr. Sands preferred the plan originally practised
by Dr. Parker to the modification afterwards proposed by Dr. Buek, although he
had found that the external incision need not exceed two inches in length.
This having been made parallel with Poupart's ligaments, and over the central
part of the tumour, the abdominal wall should be cautiously divided to the level
of the facia transversalis, when, by the aid of a hypodermic syringe thrust in
various directions, if necessary, the precise situation of the abscess could be
determined. A deep incision, half an inch in length, then completed the opera-
• tion. In one or two instances he had washed out the cavity of the abscess by
means of a syringe ; in the others it was deemed best simply to insert a tent or a
drainage-tube.
Lastly, Dr. Sands stated that he believed there was little danger of wounding
the peritoneum during the operation, and that he thought the relations of this
membrane to the abscess were often misunderstood. It was commonly held that
in perityphlitis due to perforation of the vermiform appendix, the matter was
situated in the peritoneal cavity, and the abscess circumseribed partly by Coils of
1878. J
Domestic Summary.
583
intestine, adherent to one another and to the adjacent abdominal -wall. But he
was certain that this was not the case, and that whenever perforation took place
directly into the peritoneal sac, fatal peritonitis speedily ensued. AVhen circum-
scribed abscess was about to form, he believed that perforation of the appendix
was preceded by adhesion of the serous membrane investing the appendix to that
lining the iliac fossa, obliterating at that point the peritoneal cavity. Perforation
then occurring, the fecal matter or foreign body escaped into the loose connective
tissue behind the caecum, and gave rise to suppuration, which, as it extended,
usually stripped off' and pushed aside the peritoneal membrane, which therefore
would not be endangered by the usual incision made over the most prominent part
of the inflammatory swelling. He was confirmed in this view of the pathology
of the disease by the result of several autopsies he had either witnessed or heard
of, and in all of which the abscess was found external to the peritoneum, being
sometimes in the pelvic fascia, sometimes in the loose connective tissue of the
iliac fossa, and occasionally in that behind the ascending colon. In no case had
he seen a circumscribed perityphlitic abscess in the peritoneal sac.
On the Use of a Mixture of Bromides and Chloral in "Epilepsy.
At a late meeting of the New York Therapeutical Society (JSIed. Record,
March 2, 1878), Dr. E. C. Seguix made a preliminary report on this subject,
of which the following is a brief summary : —
The formula employed by Dr. Seguin and two of his clinical assistants was as
follows: R. — Potas. bromid. gj, chloral hydrate ^ss, aqua? §vij. — M. Of that
mixture from four to six teaspoonfuls were administered daily.
The observations were made by Dr. A. McLane Hamilton, of Kew York ; Dr.
J. C. Shaw, of Brooklyn ; Dr. E. C. Seguin, and two of his clinical assistants,
Drs. T. A. McBride and N. B. Emerson. The combination of chloral with
bromide of potassium had been used in twenty-eight cases, and it was shown that
the epileptic attacks were warded off by the new solution quite as well as by the
bromides alone (bromide of ammonium in the same quantity being used instead
of the chloral hydrate). The reflex irritability of the throat was reduced equally
as well as by the use. of the bromides alone.
In all the cases there was a remarkable immunity from the bad effects of the
bromides, especially in the psychic sphere, and little or no acne had been pro-
duced. In no case was more than forty-five grains of each drug given daily, and
really no bad results had been realized under the new treatment.
It had been hoped that the admixture of the chloral with the bromide would
diminish the evil results produced by the bromide, such as general depression of
the system, irritation of the skin, etc., and those advantages had been partially,
if not fully, realized. The good results obtained had encouraged the committee
to make a more extensive trial of the new mixture.
Extirpation of the Spleen.
~Dn. G. B. Simmons reports {Pacific Med. and Surg. Journ., "Dec. 1877) the
case of a man, aged 40, who consulted him on account of a greatly hypertrophied
spleen. On June 6, Dr. Simmons extirpated the spleen ; strong adhesions with the
diaphragm were found to exist, and the removal of the organ was effected without
the escape of any blood into the abdominal cavity. He gradually sank and died
from hemorrhage two hours and a half after the completion of the operation.
The excised spleen drained of blood weighed seven and a half pounds, and was
fifteen and a half inches long.
[This is the third time that the operation has been performed in this country.
Of the thirty-seven or thirty-eight cases of excision of the spleen which are now
584
American Intelligence.
[April 1878.
recorded,1 nineteen or twenty, in which the excision was done for traumatic causes,
all terminated favourably, while of eighteen pathological operations, at least
twelve have proved fatal.]
Diagnosis of Sciatic Dislocation of the Hip.
Dr. AY. T\r. Dawson, Professor of Surgery in the Medical College of Ohio,
calls attention {Hospital Gazette, Jan. 1, 1878) to "a hitherto unrecognized
symptom of sciatic dislocation of the head of the femur," which he describes as
follows : If the patient be placed upon his back with the limbs extended there
will be but very little shortening, but if the thighs "be flexed upon the trunk at a
right angle, then the knee of the dislocated limb will sink below that of the other
side from one to two inches." The explanation given is that the sciatic notch is
situated directly behind the acetabulum, so that in sciatic dislocation the limb
when flexed at a right angle is shortened the distance from the centre of the cavity
to the centre of the notch, which may be from one to two or more inches.
Dr. Dawson gives extracts from surgical writings from the time of Petit to the
present day "to show that up to this time no author, so far as I have read, had
called attention to the difference in the length of the disturbed limb when ex-
tended and when flexed at a right angle with the pelvis." He has, however,
ignored an excellent paper on " Dislocations of the Hip — Sciatic variety," pub-
lished four years ago, by Dr. Oscar H. Allis, Surgeon to the Presbyterian Hos-
pital, Philadelphia (PTiila. JMedical Times, March 28, 187-1), in which the same
" hitherto unrecognized symptom," with its rationale, is fully and accurately
described, and is illustrated in the same way by wood-cuts.
Poisoning by Custards and Ice Creams.
Dr. J. S. AVellford, Professor of Materia Medica and Therapeutics in the
Medical College of Virginia, in an interesting paper read at the late meeting of
the Medical Society of Virginia (Transactions Medical Society of Virginia,
1877), concludes, from a careful investigation of recorded cases of poisoning by
custards and ices, that the true cause is some decomposition in the albuminoid
articles used, viz. : the milk and eggs, which maybe aided perhaps by the sugar.
The symptoms described as having been produced by cheese are so exactly like
those in these cases, that we may fairly assign them to a similar cause ; and he
learns by a private letter from Dr. Kedzie, the able President of the Michigan
State Board of Health, that he has analyzed several specimens of cheese which
.had caused similar symptoms without detecting any mineral poisons whatever.
ISTearly all these cases occurred in hot weather, and in most the article had been
kept some time. Besides, when we reflect how liable milk is to become impreg-
nated with medicinal and other substances by the food and ingesta of the animal
furnishing it, Dr. TYellford thinks we may more justly attribute the symptoms to
the milk than to the flavouring. I know it has been contended that, if the vanilla
itself is not poisonous, it is frequently prepared with an oil which is or may be-
come an irritant poison ; but Dr. AYellford does not see why, if this is true, that
we do not have these cases in winter as well as in the hot seasons of the year.
1 Med. and Surg. History of War of Rebellion, Surgical Yol.,part2, p. 152, and Am.
Jour. Med. Sci., Oct. 1876, p. 488, July, 1877, p. 261, Oct. 1877, p. 578, Jan. 1878, p.
272, and April, 1878, p. 556.
IXDEX.
A.
Abraham, hydrobromic acid, 250
Abscess, mammary, treated antiseptically,
286
Accommodation, binocular, 572
Alabama Medical Association, Trans-
actions of, notice of, 458
Albumen in urine, new method of estimate
ing, 209
Alcohol, excretion of, 530
Allen, localization of diseased action in
oesophagus, 293
Aithaus, Diseases of the Nervous System,
review of, 459
, polio-myelitis, 409
Alvarenga, salicylate of soda in erysipelas,
532
Alvares, iodoform ointment in blennor-
rhagic epididymitis, 273
American Neurological Association's
Transactions, notice of, 507
Ametropia, visual acuteness in, 362
Anaesthesia, primary, from ether, 452
Anaesthetics, mode of action of, 251
Anderson, Lectures on Clinical Medicine,
notice of, 485
Aneurism, retinal, 571
Annandale, congenital malposition of tes-
ticle, operation in, 560
Antiperiodic, a tasteless, 579
Aorta, aneurism of, 275
, obliteration of, 260
, perforation of, by foreign body in
oesophagus, 549
Arnica as"a remedy for boils, 545
Arsenic, action of, on blood-richness, 74
Aschenborn, perforation of aorta by foreign
body in oesophagus, 549
Ascites from syphilitic hydraemia, 531
Ashhurst, a tasteless antiperiodic, 579
Asthma, treatment of, 535
Athetosis, 211
Atkinson, contagious vulvitis, 444
Atlee, wounds of trachea, 439
Atropia in sweating, 252
Atthill, injection of hot water in postpar-
tum hemorrhage, 574
B.
Babesiu, obstruction of bowels by a dislo-
cated spleen, 262
Bard, spontaneous perforation of popliteal
artery in a case of white swelling, 566
Barwell, aneurism of aorta, innominata,
subclavian, and carotid, treated by distal
ligature, 275
No. CL April 1878.
| Beane, rectotomy in stricture, 382
I Bergh, electricity in eye disease, 572
| Bibliographical Notices —
American Neurological Associa-
tion's Transactions, 507
Anderson, Lectures on Clinical Me-
dicine, 485
Binz, Therapeutics, 515
Bowditch, Public Hygiene in Ameri-
ca, 510
Brown-Se:piard, Convulsions and
Paralvsis as Effects of Disease of Base of
Brain. 512
California State Board of Health
Report, 519
Canada Medical Association's
Transactions, 506
Engelsted. Clinical Guide to Vene-
real Diseases, 228
Erichsen, Surgery, 488
Farquharson, Guide to Therapeu-
tics, 243
Garland, Pneumono-Dynamics, 478
Girard, Lister's System of Wound
Treatment, 240
Godard, Stuttering and its Treat-
ment, 511
Grunfeld, Urethral Catarrhs and
their Endoscopic Appearance, 516
Heaton, Cure of Rupture, 238
Holden, Landmarks, Medical and
Surgical, 496
Hutchinson. Illustrations of Clini-
cal Surgery, 241.494
Keen, Surgical Complications and
Sequels of Continued Fevers, 236
Langenbeck, Gunshot Wounds of
the Hip-joint, 219
Loomis, Lectures on Fever, 242
Liicke, Percussion of Bones, 482
Lund, Internal Urethrotomy, 487
Mason, Hare-lip and Cleft Palate,
239
— — Medico - Chirurgical Transactions ,
207, 475
Morton, Treatment of Spina Bifida
by a New Method, 511
New Haven Board of Health Report.
248
New York Pathological Society's
Transactions, 508
0.tt, Action of Medicines, 513
Parker and Bettany, Morphology of
the Skull, 21'
Public Health Reports, 213
Rhode Island Census, 520
38
586
Index.
Bibliographical Notices —
St. Thomas's Hospital Reports, 199
Smith, Retarded Dilatation of Os
Uteri in Labour, 224
State Medical Societies' Trans-
actions, 497
Strieker, Experimental and General
Pathology, 492
Tanner, Index of Diseases, 247
Toland, Lectures on Surgery, 245
West, Hospital Organization, 517
Wylie, Hospitals, 244
Ziemssen, Cyclopaedia of Practice
of Medicine, 232
Bigelow, lithotrity by a single operation,
117
Billroth, gastrorraphy, 271
, surgical treatment of broncho-
cele, 550
Binz, Therapeutics, notice of, 515
, excretion of alcohol, 530
Blood, action of certain remedies on glo-
bular richness of, 74
Boils, arnica as a remedy for, 545
Bone aneurism, diagnostic value of pulsa-
tion in, 278
, catgut employed to arrest hemor-
rhage from, 566
Bones, percussion of, 482
Bouchard, creasote in phthisis, 537
, etiology of t}Tphoid fever, 255
Bouton de Biskra, 208
Bowditch, Public Hygiene in America,
notice of, 510
Breasts, minute anatomy of eczematous,
207
Briere, retinal aneurism, 571
Blight's disease, derangement of glyco-
genesis as a cause of, 348
Bronchocele, surgical treatment of, 550
Brown, therapeutics of diphtheria, 257
Browne, extirpation of spleen, 272
Brown-^equard, Convulsions and Paralysis
as Effects of Disease of the Base of the
Brain, notice of, 512
Bruet, toxic properties of dynamite, 290
Bryant, carbolized catgut ligature, 273
, prostatic tumours removed during
lithotomy, 560
Bull, subconjunctival serous cysts, 85
Burnett, the Ear, review of, 173
, visual acuteness in ametropia, 362
Busey, vomiting of pregnancy, bromide of
potassium in uncontrollable, 110
Butlin, minute anatomy of eczematous
breasts, 207
Byasson, salicylic acid, 250
Caesarean section, statistical study of, 313
Caffeine, diuretic properties of, 528
California Board of Health Report, notice
■ of, 519
Canada Medical Association's Transac-
tions, notice of, 506
Carcinoma, parenchymatous injections of
acetic acid in, 544
Carmichael, antiseptic treatment of mam-
mary abscess, 286
Carotid, ligature of common, in case of in-
jury of external carotid, 277
Carotid, internal, ulceration of, 505
Carter, Bouton de Biskra, 208
Catgut, employed to arrest hemorrhage
from bone, 566
Challot, fusion of radial artery with me-
dian basilic vein, simulating arterio-
venous aneurism, 565
Chamberlain, relation of urinary organs to
puerperal diseases, 294
Chancre, excision of hard, as a preventive
of syphilitic infection, 559
Chapman, laryngo-thyrotomy for epitheli-
oma laryngis, 136
Cheadle, treatment of serous effusions by
limitation of fluid, 538
Cleft palate, 203, 239
Clutton, imperforate rectum, 205
Coats, pathology of tetanus and hydropho-
bia, 533
Cod-liver oil, action of, on blood, 71
Cohn, drainage of eye in detached retina,
281
production of local artificial anaemia
in treatment of diseases of the extremi-
ties, 563
Colley, resection of tarsal bones for double
talipes equino-varus, 475
Conner, sub-acroinial dislocation of hume-
rus, 450
Connor, reproduction of membrana tym-
pani, 114
Copper acetate, poisoning by, 290
sulphate, therapeutic uses of, 529
Cough, reflex, 342
I Croup, treatment of, 258
Custards, poisoning by, 584
Cutler, action of certain remedies on blood,
74
I Cysticerci in the skin, 266
Cystitis, pseudo-membranous, 561
, treatment of, 561
Cysts, subconjunctival serous, 85
D.
Dawson, sciatic dislocation of hip, 584
Da}*, ozonic ether and lard in scarlatina,
531
Debove, new symptom of paralysis agi-
tans, 532
Dejerine, lesions of anterior nerve-roots in
diphtheritic paralysis, 533
Desnos, digitalis in metrorrhagia, 576
Diabetes, cerebral commotion as a cause
of, 543
insipidus, nitric acid in, 513
, lesion of pancreas in, 513
Digitalis in disease of aortic valves, 260
Diphtheria complicating typhoid fever, 256
, therapeutics of, 257
, tracheotomy in, 551
Diuretics, action of. 527
Duboisia myoporoides, mydriatic proper-
ties of, 526
Duckworth, paralysis following exposure
to heat, 176
Dulles, supra-pubic lithotomy, 391
Duncan, investigation of interior of the
uterus by the carbolized hand, 281
Duret, treatment of syphilitic laryngitis,
534
Dynamite, toxic properties of, 290
Index.
587
E.
Ear, Burnett on, review of, 173
Easley, fracture of body of scapula, 291
Effusions, serous, treatment of, by limita-
tion of fluid, 538
Electricity in eye disease, 572 »
Engelsted, Clinical Guide to Venereal Dis-
eases, notice of, 228
Epididymitis, blennorrbagic, iodoform oint-
ment in, 273
Epilepsy, use of mixture of bromides and
chloral in, 583
, uses of iron in, 257
Epithelioma, some of the changes found
in, 211
Erichsen, Surgery, notice of, 488
, ulceration of internal carotid, 565
Erysipelas, salicylate of soda in, 532
Exostoses, subcutaneous fracture of, 566
Extremities, local ana?mia in treatment of
diseases in, 563
Eye ground, appearance of, in general
anaemia, 570
F.
Farquharson, Therapeutics, notice of, 213
Fat and Blood, review of, 192
Feltz, poisoning by acetate of copper, 290
Fevers, surgical complications and se-
quences of continued, 257
Forbes, nitrite of amyl in hydrophobia, 402
Formad, distribution of nerves in iris, 93
Fothergill, digitalis in aortic disease, 260
, opium poisoning successfully
treated by atropia, 578
Foulis, extirpation of larynx, 268
Fournier, iodic purpura, 263
Fox, pigmentary s}'philide, 356
G.
Galabin, water-hammer pulse, 212
Galezowski, migraine of eye, 568
, pilocarpin, 252
■ , salicylate of soda in rheumatic
iritis, 569
Garland, Pneumono-Dvnamics, notice of,
478
Gastric juice, acidity of, 249
, diminution of, in
fevers, 254
Gastro-hysterotomy, 313
Gastrorraphy, 271
Gemmell, salicine in rheumatism, 255
Genu valgum, pathogenesis of, 565
Georgia Medical Association, Transactions
of, notice of, 499
Gerdes, extirpation of larynx, 555
Gies, parenchymatous injections of acetic
acid in carcinoma, 544
Girard, Lister's System of Wound Treat-
ment, notice of, 240
Girgensohn, simple plan of emptying the
pleural cavity, 555
Glaucoma, acute, following instillation of
atropia, 569
, sclerotomy in, 280
Glisan, apomorphia in strychnia poisoning,
448
Godard, stuttering, 511
Gowers, athetosis and post-hemiplegic dis-
orders of movement, 211
Gowers, uses of iron in epilepsy, 257
Greenfield, diphtheria complicating ty-
phoid fever, 256
Grunfeld, urethral catarrhs, 516
Grutzner, action of diuretics, 527
Gubler, diuretic properties of caffeine, 528
Gueniot, ano-pelvic version, 574
Guttman, cysticerci in skin, 266
Guyon, drainage in suppurative otitis, 283
Guyot, pseudo-membranous cystitis, 561
H.
Hare-lip and Cleft Palate, notice of Mason
on, 239
Harris, gastro-hysterotomy, 313
Hartshorne, theory of ocular spectra, 447
Haynes, purulent pelvic effusion opening
spontaneously into vagina, 153
Heart disease, bearing of, upon pregnancy,
287
, syphilis of, 541
Heaton, Cure of Rupture, notice of, 238
Heidenhain, etiology of pneumonia, 258
Hemorrhage from bone, catgut employed
to arrest, 566
, post-partum, injection of hot
water in, 574
Hemorrhoids, glycerine in treatment of
internal, 562
Henoch, syphilis of testis in young child-
ren, 559
Henry, reduction of old dislocation of hip,
134
Hernia, congenital ventral, 558
, Heaton, radical cure of, 238
, use of testicle in radical cure of,
152
Hewitt, abnormal softness of nulliparous
uterus a cause of uterine disorder, 288
Hip-joint, observations on gunshot wound
of, 47
, old dislocation of, successfully re-
duced, 134
, sciatic dislocation of, 584
Hirschberg, appearance of eye-ground in
general anaemia, 570
H olden, Landmarks, Medical and Surgi-
cal, notice of, 496
Huidiez, retinitis pigmentosa, without visi-
ble pigment, 570
Humerus, sub-acromial dislocation of, 450,
567
Hunter, use of testicle in radical cure of
hernia, 152
Hutchinson, Illustrations of Clinical Sur-
gery, 241, 494
Hydramnios, etiology of, 199
Hydrobromic acid, 250
Hydrocele of the cord, 273
of the tunica vaginalis, 204
Hydrophobia, nitrite of amyl in, 402
— - , pathology of, 533
I.
Ice cream, poisoning by, 584
Indiana State Medical Society's Trans-
actions, notice of, 504
Indican, excretion of, in disease, 253
Inflammation, oedema and lymph-stream
in, 266
Innominate, aneurism of, 275
583
Index.
International Medical Congress of Phila-
delphia, review of Transactions of, 155
Intestinal obstruction from dislocated
spleen, 262
Iris, distribution of nerves in, 93
Iritis, salicylate of soda in rheumatism,
569
Iron, action of, on richness of blood, 74
Ishiguro, ligature of whale sinew, 580
J.
Jordan, hydrocele of the cord, 273
K.
Kakke, 199
Kansas Medical Society's Transactions,
notice of, 505
Kaposi, excision of hard chancre as a pre-
ventive of syphilitic infection, 559
, lichen rubber acuminatus and pla-
nus, 265
, molluscum contagiosum, 265
, psoriasis universalis, 543
, zoster recidivus, 266
Keen, Surgical Complications and Sequels
of Continued Fevers, notice of, 236
Kehrer, septic influence of lochial dis-
charge,- 285
Keith, cases of ovariotomy, 57'6
Kellogg, treatment of melancholies and
suicides, 109
Kennedy, nitric acid in diabetes insipidus,
543
Kentucky State Medical Society's Trans-
actions, notice of, 500
Key, s}rphilitic disease of kidneys and
heart, 541
Kidney, extirpation of, 557
Kidne}?s, sj^philis of, 541
King, suffering from deprivation of water,
404
Kocher, extirpation of kidney, 556
Koester, ulcers from use of enemata, 563
Kraussold, resection of median nerve, "379
Kronlein, tracheotomy in diphtheria, 551
Kiihne, colouring matter of retina, 523
L.
Labour, normal, during extra-uterine preg-
nancy, 574
Labutut, normal labour during extra-
uterine pregnancy, 574
Lanceraux, lesion of pancreas in diabetes,
543
, visceral syphilis, 540
Landi, diagnostic value of pulsation in true
aneurism, 278
Langenbeck, foreign bodies in oesophagus,
545
, Gunshot Wounds of the Hip-
joint, notice of, 219
Lapponi, subcoracoid dislocation of hume-
rus by muscular contraction, 567
Laryngitis, treatment of syphilitic, 534
Laryngo-tracheotomy for removal of papil-
lomatous growth in larynx, 552
Larynx, epithelioma of, removed bylaryn-
go-thyrotomy, 136
, extirpation of, 268, 555
, lupus of, 370
Larynx, papillomatous growth in, removed
by laryngo-tracheotomy, 552
Lassar, oedema and lymph stream in in-
flammation, 366
Lebert, treatment of neurosis of stomach,
261
Lcderer, mela?na neonatorum, 530
Lefferts, lupus of the larynx, 370
Legg, complete obliteration of aorta, 260
Levi, therapeutic uses of sulphate of cop-
per, 529
Lichen ruber acuminatus and planus, 265
Ligature, carbolized catgut, 273
Ligatures from the sinew of the whale, 580
Lister, laryngo-tracheotomy for large pa-
pillomatous growth in larynx, 552
Lister's System, notice of Girard on, 240
Lithotomy, supra-pubic, 394
Lithotrity by a single operation, 117
Lochial discharge, septic influence of, 285
Loomis, Lectures on Fever, notice of, 241
Liicke, percussion of bones, 482
Lund, Internal Urethrotomy, notice of, 487
Lung elasticity, some effects of, 210
M.
MacCormac, removal of scapula, 206
Macdonald, bearing of heart disease upon
pregnancy, 287.
Mackiewicz, milk diet in nephritis, 542
Magnus, acute glaucoma following instil-
lation of atropia, 569
Malarious waters, 17
Martin, extirpation of spleen, 556
Mason, cleft palate, 203
Maunder, subcutaneous fracture of exos-
toses, 566
Maury, tattooing as a means of communi-
cating syphilis, 44
Mauthner, sclerotomy in glaucoma, 280
Medico-Chirurgical Transactions, notice
of, 207, 475
Melsena neonatorum, 530
Melancholies, treatment of. 100
Membrana tyinpani, reproduction of, 114
Membranous entero-colitis, 146
Menstruation and ovulation, 292
, study of 100 cases of, 293
Metrorrhagia, digitalis in, 576
Michel, paralysis of eye muscles, 572
Migraine of eye, 568
Minnesota State Medical Society's Trans-
actions, notice of, 497
Mitchell, Fat and Blood, review of, 192
Molluscum contagiosum, 265
fibrosum, 145
Monti, ascites from syphilitic hydrsemia,
531
Morton, nerve stretching, 150
, treatment of spina bifida, 517
Mountain fever, 17
Mucous disease, 148
Muhlenberg, membranous entero-colitis,
146
Munde, ovariotomy during peritonitis, 100
Murmur, presystolic, 201
Muscles, paralysis of eye, 572
Mydriatic properties of duboisia myopo-
roides, 526
Myelitis, acute anterior, in adults, 409
Index.
589
Nephritis, milk diet in, 542
Nerve, resection of median, without dis-
turbance of sensation, 279
stretching, 150
Nervous disorder, notes on cases of, 200 '
New Hampshire Medical Society's Trans-
actions, notice of, 500
Haven Board of Health Report, no-
tice of, 248
Jersey Medical Society's Transac-
tions, notice of, 497
York Pathological Society's Trans-
actions, notice of, 508
North Carolina Medical Society's Trans-
actions, notice of, 501
O.
(Esophagus, foreign bodies in, 545
, body in, perforating
aorta, 549
, localization of diseased action
in, 293
Oldoini, treatment of croup, 258
Opium poisoning successfully treated by
atropia, 578
Orbit, acute cellulitis of, 281
Orth, Pathological Anatomy, review of,
465
Osborn, hydrocele of tunica vaginalis, 204
Os uteri, retarded dilatation of^ in labour,
224
Otitis, suppurative, drainage in, 283
Ott, Action of Medicines, notice of, 513
Ovariotomy during peritonitis, 100, 289
, Keith's cases of, 576
Packard, primary anaesthesia from ether,
452
Panas, on the treatment of ranula, 268
Pancreas, lesion of, in diabetes, 543
Paquelin, phosphate of lime, 251
Paralysis agitans, new symptom of, 532
, diphtheritic, lesions of anterior
nerve roots in, 533
, following exposure to heat, 476
Parker, Morphology of the Skull, notice of,
247
Parvin, study of 100 cases of menstruation,
293
Pelvic effusion, purulent, opening sponta-
neously into vagina, 153
Pennsylvania Medical Society's Trans-
actions, notice of, 501
Pericardial adhesions, diagnosis of extra-,
538
Perityphilitis, 581
Pernot, carbolate of soda in pertussis, 534
Pfahl, pyopneumothorax simulated by lo-
calized peritoneal exudation, 262
Phosphate of lime, 251
Phosphatic deposits, cysto-, pathological
history of, 561
Phthisis, contagiousness of, 426
, creasote in, 537
Pigmentary syphilide, 356
Pilocarpin, action of, on eye, 252
Planat, arnica as a remedy for boils, 545
Pleural cavity, simple plan of emptying,
555
Pneumonia, etiology of, 258
Pogacnik, cold douches in tuberculosis,
259
Poisons, post-mortem, imbibition of,- 294
Polaillon, dislocation of xiphoid cartilage
during pregnancy, 573
Polio-myelitis, 409
Poore, disease of sacro-iliac synchondro-
sis, 62
Popliteal artery, spontaneous perforation
of, by a white swelling, 566
Porcher, molluscum fibrosum, 145
Post-hemiplegic disorders of movement,
211
Powell, lung elasticity, 210
Prostatic tumours removed during litho-
tomy, 560
Psoriasis, acetic acid in, 266
universalis, 543
Public Health Reports, notice of, 213
Puerperal diseases, relation of urinary or-
gans to, 294
fever, prophylaxis of, 576
Pulse, water-hammer, 212
Purpura, iodic, 263
Pyopneumothorax simulated by localized
peritoneal exudation, 262
Quinetum, 528
Q.
R.
Radial artery, fusion of, with median ba-
silic vein, simulating an arterio-venous
aneurism, 565
Ranke, mode of action of anaesthetics, 251
, thymol, 524
Ranula, on the treatment of, 268
Rectotomy in stricture, 382
Rectum, imperforate, 205
, stricture of, rectotomy in, 382
Reese, post-mortem imbibition of poisons,
294
Retina, colouring matter of, in relation to
vision, 523
— > , drainage of eye in detached, 281
functions of, 521
Retinitis pigmentosa without pigment
visible, 570
Reviews —
Althaus, Diseases of the Nervous
System, 459
Burnett, The Ear, 173
International Medical Congress oi
Philadelphia, Transactions of, 155
Mitchell, Fat and Blood, 192
Orth, Pathological Anatomy, 465
Sayre, Spinal Diseases, 453
Woodman and Tidy, Forensic Medi-
cine and Toxicology, 181
Rheumatism, salicine in, 255
Rhode Island Census, notice of, 520
Richet, acidity of gastric juice, 249
Riedinger, catgut to arrest hemorrhage
from bone, 566
Ringer, duboisia myoporoides, 526
Rizzoli, congenital ventral hernia, 558
Roberts, new method of estimating albu-
men in urine, 209
Robin, cerebral commotion as a cause of
transient glycosuria, 543
590
Index.
Robinson, paralysis of abductors of vocal
cord, 378
Royet, atropia in sweating, 252
Ruggi, ligature of common carotid in in-
jury of external carotid, 277
Rumpf, binocular accommodation, 572
S.
Sacro-iliac synchondrosis, disease of, 62
Saint Thomas's Hospital Reports, notice
of, 199
Salieine in rheumatism, 255
Salicylic acid, 250
Sands, perityphlitis, 581
Sayre, Spinal Disease, review of, 453
Scapula, fracture of body of, 291
, removal of, 206
Scarlatina, use of ozonic ether and lard
in, 531
Sclerotomy in glaucoma, 280
Sea, treatment of asthma, 535
Seguin, use of mixture of bromides and
chloral in epilepsy, 583
Senator, excretion of indican, 253
Simmons, extirpation of spleen, 583
Smart, mountain fever and malarious wa-
ters, 17
Smith, gl}*cogenesis and Bright's disease,
348
. paralvsis of abductors of vocal
cords, 143
, reflex cough, 342
, Retarded Dilatation of Os Uteri in
Labour, notice of, 224
Sonnenberg, acute cellulitis of orbit, 281
Spectra, ocular, theory of, 447
Spleen, dislocated, causing intestinal ob-
struction, 262
, extirpation of. 272. 556, 583
Stomach, treatment of neurosis of, 261
Strieker's Pathology, notice of, 492
Strychnia poisoning, apomorphia in, 448
Stuttering, treatment of, 511
Subclavian aneurism, treated by distal
ligature, 275
Suicides, treatment of, 109
Sweating, atropia in, 252
Syphilis, tattooing as a means of commu-
nicating. 44
, visceral, 540, 541
T.
Tait, ovariotomy during peritonitis, 289
Tanner, Index of Diseases, notice of, 247
Tarsal bones, resection of, for double con-
genital talipes equino-varus, 475
Tattooing as a means of communicating
syphilis, 44
Testicle, congenital malposition of, suc-
cessfully treated by operation, 560
, syphilis of, in young children. 559
, use of, in radical cure of hernia,
152
Tetanus, pathology of. 533
Texas State Medical Association, notice of
Transactions of, 497
Thin, changes in epithelioma, 211
Thomas, menstruation and ovulation. 292
Thompson, cvsto-phosphatic deposits, 561
Thymol, 524
Toland. Lectures on Surgery, notice of, 245
Trachea, treatment of wounds of, 439
Tracheotomy in diphtheria, 551
, laryn^o-, for larsre papillo-
matous growths in larynx, 552
Trichinosis, chronic muscular svmptoms
after, 434
Tuberculosis, cold douches in, 259
Tweedy, duboisia myoporoides, 526
Typhoid fever, etiology of, 255
U.
Dicers from use of enemata, 564
Urethrotomy, internal, 787
Uterus, abnormal softness of nulliparous,
cause of uterine disorder, 288
, investigation of interior of, by car-
bolized hand, 284
V.
Velden, diminution of acidity of gastric
juice in fever, 254
Verneuil, pathogenesis of genu valgum.
565
Version, ano-pelvic, 574
Vertigo, stomachic and labyrinthine. 419
Vinkhuysen, quinetum, 528
Vocal cords, paralvsis of abductors of. 143.
378
Voice, preservation of, after removal of
vocal cords, 552
Vomiting of pregnancy, uncontrollable,
bromide of potassium in, 140
Vulvitis, contagious, 444
TV
Water, suffering from deprivation of, 404
Webb, contagiousness of phthisis, 426
Wellford, poisoning by custards and ice
creams, 584
Wendt. chronic muscular symptoms after
trichinosis, 434
West, Hospital Organization, notice of, 517
White, treatment of cystitis. 561
Whooping-cough, carbolate of soda in. 534
Widmann. diagnosis of extra-pericardial
adhesions, 538
Woakes, stomachic and labvrinthine ver-
tigo, 419
Woodman and Tidy, Forensic Medicine,
review of, 181
Wylie, Hospitals, notice of, 244
X.
Xiphoid cartilage, dislocation of, during
pregnancy. 573
Y.
Teo, laryngo-tracheotomy for large multi-
ple papillomatous growth in larynx, 552
Young, glycerine in treatment of internal
hemorrhoids, 562
Z.
Ziemssen, Cyclopaedia of Practice of Medi-
cine, notice of, 232
Zoster recidivus. 266
Zweifel, prophylaxis of puerperal fever,
576
American Journal of Medical Sciences.
501
UNIVERSITY OF PENNSYLVANIA.
MEDICAL DEPARTMENT.
Thirty- Sixth Street and Woodland 4-venue (Darby Road), Philadelphia.
One Hundred and Thirteenth Annual Session, 1878-79.
PROFESSORS.
CHARLES J. STILLE, LL.D., Provost.
GEORGE B. WOOD, M.D., LL.D., Emeritus Pro-
fessor of Theorv and Practice of Medicine.
HENRY H. SMITH, M.D., Emeritus Professor of
Surgery.
FRANCIS G. SMITH, H D.. Emeritus Professor
of the Institutes of Medicine.
JOHN NBILL, M.D., Emeritus Professor of Clini-
cal Surgery.
JOSEPH LEIDT, M.D., LL.D., Professor of Ana-
tomv.
RICHARD A. F. PENROSE, M.D., LL.D., Pro-
fessor of Obstetrics and Diseases of Women
and Children.
ALFRED STILLE, M.D., LL.D., Professor of
Theory and Practice of Medicine, and Clini-
cal Medicine.
D. HAYES AG NEW, M.D., LL.D., John Rhea
Barton Professor of Surgery and Clinical
Surgery.
HORATIO C. WOOD, M.D., Professor of Materia
Medica, General Therapeutics, and Phar-
macv.
WILLIAM PEPPER, M.D., Professor of Clinical
Medicine.
WILLIAM GOODELL, M.D , Professor of Clini-
cal Gvnsecology.
JAMES TYSON, M.D. , Professor of General Pa-
thology and Morbid Anatomy.
THEODORE G. WORMLEY, M.D., LL.D., Pro-
fessor of Chemistry.
JOHN ASHHURST, Jr., M.D., Professor of Clini-
cal Surgery.
, Professor of Pbvsiology *
WILLIAM F. NORRIS, M.D , Clinical Professor
of Diseases of the Eye.
GEORGE STRAWBRIDGE, M.D., Clinical Pro-
fessor of Diseases of the Ear.
HORATIO C. WOOD, M.D., Clinical Professor
of Nervous Diseases.
LOUIS A. DUHRING. M.D., Clinical Professor of
Diseases of the Skin.
New matriculates are required to attend three winter courses of instruction of five months each,
consisting of graded didactic lectures, cliuical lectures, and practical work in laboratories and hos-
pitals.
In the graded curriculum adopted, the elementary branches are taught in the first course, and
students are finally examined at its conclusion upon General Chemistry, Materia Medica, and
Pharmacy. In the second term, while a sufficient repetition of unfinished branches is secured,
certain more practical ones are added, and the examinations on Anatomy, Physiology, Medical
Chemistry, and General Pathology and Morbid Anatomy at the end of the term are final. In the
third course is added practical bedside instruction in Medicine, Surgery, aud Gynaecology, with
clinical facilities in the' specialties; and, at its end, students are examined on Therapeutics,
Theory and Practice of Medicine, Surgery, and Obstetrics.
Students, who have attended one course in a regularf medical school , will be admitted as students
of the second course in the University, after having satisfactorily passed an examination in General
Chemistry and Materia Medica and Pharmacy. Students who have attended two courses in a regular
medical school, will be admitted as students of the third course after examination in General and
Medical Chemistry, Materia Medica and Pharmacy, Anatomy, and Physiology.
Graduates of other regular medical schools in good standing will be admitted as students of the
third course in this institution without any examination.
Graduates of Colleges of Pharmacy and Dental Colleges in good standing are admitted to the
second, course in the University without an examination.
In the Spring session, beginning the first Monday in April, a valuable course on practical and
scientific subjects by a large corps of professors and lecturers \% given; and the laboratories of
Chemistry, Pharmacy, Histology, Physiology, and Pathology are open, affording a valuable post-
graduate course.
The Lectures of the Winter Sess ion of 1S7S-79 will be gin on Tuesday the first day of October, and
end on the last day of February.
The Preliminary Course wilt begin on .Monday, Sept. 9th.
Fees, in advance. — 1st course of lectures, including matriculation and dissection, $155. Dissect-
ing material free. 2d course $140. 3d course $100 Graduation fee $30.
For Announcement giving full particulars address
JAMES TYSON, M.D., Secretary,
P. O. Box 2838, Philadelphia.
DEXTAL DEPARTMENT.
The Trustees have established a Dental Department, which it is designed to make the most com-
plete school of Dentistry in the world. The professors include those of Anatomy, Physiology,
Chemistrv, and Materia Medica, in the Medical Department, with Chas. J. Essie, M.D , D.D S.,
Prof, of Mechanical Dentistry and Metallurgy, aud Edwin T. Dare-v, D.D.S., Prof, of Operative
Dentistry. Two years* study, two courses of lectures, and examination at the end of the second
course, are the requirements for graduation. Graduates of the Dental Department of the University
may become candidates for the degree of Doctor of Medicine after attending one additioual course
of lectures.
Fees.— Matriculation $5. For one course of lectures $100. Dissecting fee $10. Graduation fee $30.
Sessions commence as those of the Medical Department For Announcement address Chas. J.
Essig, MD., D.D.S , Secretary, Dental Department, University of Pennsylvania.
* The course on Physiology during the coming session will be delivered by Prof. Tyson.
f Homoeopathic and Eclectic schools are not recognized as being in this category.
592
American Journal of Medical Sciences.
BELLEVUE HOSPITAL MEDICAL COLLEGE, CITY OF
NEW YORK.
SESSIONS OF 18 78 -'79.
The Collegiate Year m this Institution embraces a Preliminary Autumnal Term,
the regular Winter Session, and a Spring Session.
The Preliminary Autumnal Term for 1878-1879 will open on Wednesday, Septem-
ber 18, 1878, and contiuue until the opening of the Regular Session. During this
term, instruction, consisting of didactic lectures on special subjects, and daily clinical
lectures, will be given, as heretofore, by the entire Faculty. Students expecting
to attend the Regular Session are strongly recommended to attend the Preliminary
Term, but attendance during the latter is not required. Daring the Preliminary Term
clinical and didactic Lectures will be given in precisely the some number and order as in
the Regular Session.
The Regular Session will begin on Wednesday, October 2, 1878, and end about
the 1st of March, 1879.
FACULTY.
Isaac E Taylor, M D., Emeritus Professor of Obstetrics and Diseases of Women, and
President of the Faculty.
Jambs R. Wood, M.D , LL.D. , Emeritus Professor of Surgery.
Fordyck Barker, M.D., Professor of Clinical Midwifery and Diseases of Women.
Austin Flint, M.D., Professor of the Principles and Practice of Medicine and Clinical
Medicine.
W. H. Van Buren, M.D., Professor of Principles and Practice of Surgery, Diseases of
Genito-Urinary System, and Clinical Surgery.
Lewis A. Sayre, M.D., Professor of Orthopedic Surgery, and Clinical Surgery.
Alexander B. Mott, M.D. , Professor of Clinical and Operative Surgery.
William T. Lusk, M D., Professor of Obstetrics and Diseases of Women and Children,
and Clinical Midwifery.
Edmund R. Peaslee. M.D., LL.D , Professor of Gynaecology.
William M. Polk, M.D., Professor of Materia Medica and Therapeutics, and Clinical
Medicine.
Austin Flint, Jr., M D., Professor of Physiology and Physiological Anatomy, and Sec-
retary of the Faculty.
Joseph D. Bryant, M.D., Professor of General, Descriptive, and Surgical Anatomy.
R. Ogden Doremus, M.D., LL.D., Professor of Chemistry and Toxicology.
Edward G. Janeway, M.D., Professor of Pathological Anatomy and Histology, Diseases
of the Nervous System, and Clinical Medicine.
PROFESSORS OF SPECIAL DEPARTMENTS, ETC.
Henry D. Noyes, M.D., Professor of Ophthalmology and Otology.
John P. Gray, M D , LL.D., Prof, of Psychological Medicine and Medical Jurisprudence.
Erskine Mason, M.D., Clinical Professor of Surgery.
Edward L. Keyes, M.D., Professor of Dermatology, and Adjunct to the Chair of Prin-
ciples of Surgery.
J. Lewis Smith, M.D., Clinical Professor of Diseases of Children.
Leroy Milton Yale, M D., Lecturer Adjunct upon Orthopedic Surgery.
A distinctive feature of the method of instruction m this College, is the union of
clinical and didactic teaching. All the lectures arc given within the hospital grounds.
During the Regular Winter Session, in addition to four didactic lectures on every
week-day, except Saturday, two or three hours are daily allotted to clinical instruction.
The Spring Session consists chiefly of Recitations from Text-books. This term
continues from the first of March to the first of June. During this Session, daily
recitations in all the departments are held by a corps of examiners appointed by the
Faculty. Regular Clinics are also given in the Hospital and in the College building.
Fees for the Eegular Session.
Fees for Tickets to all the Lectures during the Preliminary and Eegular Term, including
Clinical Lectures $140 00
Matriculation Fee .............. 5 00
Demonstrator's Ticket (including material for dissection) 10 00
Graduation Fee 30 00
Fees for the Spring Session.
Matriculation (Ticket goad for the following Winter) $.5 00
Recitations, Clinics, and Lectures ............ 3.3 00
Dissection (Ticket good for the following Winter) 10 00
Students who h"ve attended two fvll Winter courses of lectures may be. examined at the. end rf
their second courseupon Materia Medica, Physiology, Anatomy, and Chemistry, and, if successful ,
they will be examined at the end of their third coarse upon Practice cf Medicine, Surgery, and
Obstetrics oniy.
For the Annual Circular and Catalogue, giving regulations for graduation and other information,
address Prof. Austin Flint, Jr., Secretary Bellevue Hospital Aledical College.
Date Due
SMITHSONIAN INSTITUTION LIBRARIES
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